Dillard Drive Elementary PTA

Gift Card – Check Request Form

Circle One: Stone’s Education Superstore Gift Card or Refund Request

Complete the information below and return to PTA for the Stone’s gift card OR keep this form until you are ready to turn in your receipt. The form must be completed in full for the refund.

Date:	Grade:
Teacher:
Purpose for gift card or refund:

__________________________________________________________

This additional information must be completed in order to receive a refund check.

Total Refund Due:	$	Store / Location*:
Maximum Refund is $50 Please itemize your purchase in the space(s) below. Indicate quantity ( ). Continue on back if needed.
(1) Example

** Print Clearly **

To Whom Should Check Be Paid:
Address:
City/Zip:	Phone:

Remember to Include Your Receipt with this Refund Request

*Use a new form for each business/store for which you have a receipt.

For PTA Only Authorization For PTA Only
____________________________	___________________________
President’s (or President-Elect’s) Signature	Treasurer’s Signature
Date:	Date:

FOR TREASURER’S USE ONLY: Check Number __________

Date Paid ______________

Other Information:_______________________________________________