Great Lakes Scrip Center Master Template Page

Organization Information

Organization Name:
Organization Phone Number:
Street Address:
City:
State:
Zip Code:
Does your organization currently have a scrip program in operation? Yes No
Number of families in your organization:

Coordinator Information

First Name:		Last Name:
Home Phone:		Alternate Phone:
Email Address:
Reenter Email Address:

Permanent/Default Shipping Address


Attention:
Company/Location:
Room/Floor/Suite:
Street Address:	(NO PO Boxes)
City:
State:
Zip Code:

Method of Payment

ACH Checking –Automated Clearing House (ACH) is the primary network for electronic funds transfers between banks and credit unions. It’s the same trusted federal banking network used for direct deposit payroll, social security and tax refunds, and millions of other electronic payments. Most GLSC customers choose to pay for their orders with ACH because we can begin working on your order immediately after you submit it, without waiting for payment. We will need a copy of a voided check with your signed enrollment form.
ACH Savings – This is an ACH debit posted to your Savings account. Please note, Federal banking laws limit the number of "not-in-person" withdrawals. Please provide documentation from your bank showing your account information if you wish to use ACH Savings. We will need a note from your bank with your account and routing numbers included when you send in your signed enrollment form.
Paper check – Choose this option if you wish to write a check for each of your organization orders. Also, please note that GLSC will begin processing your order when your payment is received, not when your order is submitted.

How Did You Hear About Us?

Please check all that apply (at least one selection is required)

Heard about you from a friend
Visited glscrip.com or ShopWithScrip.com
Saw you at a trade show
Received a direct mail piece from you (postcard, flyer, etc.)
Saw a magazine advertisement about you
Heard about you from a retailer location or website
You called me
Other:

Referral Code: What's This?

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