Student's Name
Student's Grade
1
2
3
4
5
6
7
8
9
Adult
Only order for
one
student at a time.
If you order for more than more than one student, your order
will not
process properly.
Sorry for any inconvenience this may cause you.
Aug 19 - Teriyaki Chicken & Veggie with White:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 19 - Orange Chicken with White Rice:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 26 - Teriyaki Chicken & Veggie with White:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 26 - Orange Chicken with White Rice:
$3.00
Quantity:
Item Subtotal:
$0.00
September 2--No School
Sep 9 - Teriyaki Chicken & Veggie with White:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 9 - Orange Chicken with White Rice:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 16 - Teriyaki Chicken & Veggie with White:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 16 - Orange Chicken with White Rice:
$3.00
Quantity:
Item Subtotal:
$0.00
Chick-Fil-A - Tuesday
Aug 13 - Chicken Sandwich:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 13 - 8 Piece Nuggets:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 20 - Chicken Sandwich:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 20 - 8 Piece Nuggets:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 27 - Chicken Sandwich:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 27 - 8 Piece Nuggets:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 3 - Chicken Sandwich:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 3 - 8 Piece Nuggets:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 10 - Chicken Sandwich:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 10 - 8 Piece Nuggets:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 17 - Chicken Sandwich:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 17 - 8 Piece Nuggets:
$3.00
Quantity:
Item Subtotal:
$0.00
Domino's Pizza - Wednesday
Domino's Pepperoni Pizza (1 Slice)
Aug 14 - Pizza Slice:
$1.00
Quantity:
Item Subtotal:
$0.00
Aug 21 - Pizza Slice:
$1.00
Quantity:
Item Subtotal:
$0.00
Aug 28 - Pizza Slice:
$1.00
Quantity:
Item Subtotal:
$0.00
Sep 4 - Pizza Slice:
$1.00
Quantity:
Item Subtotal:
$0.00
Sep 11 - Pizza Slice:
$1.00
Quantity:
Item Subtotal:
$0.00
Sep 18 - Pizza Slice:
$1.00
Quantity:
Item Subtotal:
$0.00
Costa Vida - Thursday
Aug 15 - Cheese Quesadilla with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 15 - 2 Cheese Quesadillas with No Sides:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 15 - Sweet Pork Taco with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 15 - Chicken Enchilada with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 15 - Small Sweet Pork Salad:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 22 - Cheese Quesadilla with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 22 - 2 Cheese Quesadillas with No Sides:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 22 - Sweet Pork Taco with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 22 - Chicken Enchilada with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 22 - Small Sweet Pork Salad:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 29 - Cheese Quesadilla with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 29 - 2 Cheese Quesadillas with No Sides:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 29 - Sweet Pork Taco with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 29 - Chicken Enchilada with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Aug 29 - Small Sweet Pork Salad:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 5 - Cheese Quesadilla with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 5 - 2 Cheese Quesadillas with No Sides:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 5 - Sweet Pork Taco with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 5 - Chicken Enchilada with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 5 - Small Sweet Pork Salad:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 12 - Cheese Quesadilla with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 12 - 2 Cheese Quesadillas with No Sides:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 12 - Sweet Pork Taco with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 12 - Chicken Enchilada with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 12 - Small Sweet Pork Salad:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 19 - Cheese Quesadilla with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 19 - 2 Cheese Quesadillas with No Sides:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 19 - Sweet Pork Taco with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 19 - Chicken Enchilada with Rice:
$3.50
Quantity:
Item Subtotal:
$0.00
Sep 19 - Small Sweet Pork Salad:
$3.50
Quantity:
Item Subtotal:
$0.00
Maverik - Friday
Aug 16 - Hot Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Aug 16 - Corn Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Aug 16 - Box of Mini Tacos:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 23 - Hot Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Aug 23 - Corn Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Aug 23 - Box of Mini Tacos:
$3.00
Quantity:
Item Subtotal:
$0.00
Aug 30 - Hot Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Aug 30 - Corn Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Aug 30 - Box of Mini Tacos:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 6 - Hot Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Sep 6 - Corn Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Sept 6 - Box of Mini Tacos:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 13 - Hot Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Sep 13 - Corn Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Sept 13 - Box of Mini Tacos:
$3.00
Quantity:
Item Subtotal:
$0.00
Sep 20 - Hot Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Sep 20 - Corn Dog:
$1.75
Quantity:
Item Subtotal:
$0.00
Sep 20 - Box of Mini Tacos:
$3.00
Quantity:
Item Subtotal:
$0.00
Total:
$0.00
Payer's Information
First Name:
Last Name:
Address:
Address:
City:
State/Province:
ZIP/Postal Code:
Phone:
Email:
Payment Information
Method of Payment:
Visa
MasterCard
Discover Card
Personal Checking
Personal Savings
Business Checking
Processing Fees:
Credit cards:
1%
eChecks:
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on Checking Account:
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on Savings Account:
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on Checking Account:
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Expiration Date:
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2019
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Schools 800-764-0844 Clinton UT
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