Enrollment Form
Etz Hayim Synagogue Scrip Program

Program rules and guidelines

1. All card orders must be accompanied by a check or money order made payable to Etz Hayim Synagogue. Please do not send cash. Cash payments will be accepted in person only. Scrip card payments are not tax deductible because you receive dollar for dollar value.
   
2. Order forms may be downloaded from www.etzhayim.org, and are in MSExcel and pdf formats. They may be printed and mailed to Etz Hayim Synagogue, PO Box 1600, Derry, NH 03038, or delivered to the churchagogue anytime our Education program is in session. You may also email them to medrek9352@aol.com, however, the order will not be processed until payment is received.
   
3. Checks are preferred as it keeps administrative costs down, however, if it is a genuine convenience to use your credit card, we will be happy to accept them. Credit cards will not be accepted for purchases of cards where the (average) discount to Etz Hayim is less than 5%. The discount rates are specified on the order form.
   
4. Orders will be processed each Thursday and cards will be available for pickup at the churchagogue by the following Tuesday. If you have selected to have the cards mailed to you, they will be mailed to you but at your own risk (cards = cash). To keep administrative costs down, we prefer you choose to pick up your cards Etz Hayim.
   
5. Shaw's Supermarket cards are kept in stock and are available for immediate purchase.
   
6. If there are insufficient orders for the week, where the discount will not cover shipping costs, the order may be delayed until the following week. You will be notified by email.
   
7. If your check is returned because of non-sufficient funds (NSF), you will be charged a $20 fee payable to Etz Hayim Synagogue. After two NSF checks are tendered on your account, your scrip ordering privileges will be limited to money order only.
   
8. Scrip certificates are purchased on your behalf, and are not returnable.
   
9. Scrip certificates are the same as cash, and should be handled accordingly. Etz Hayim Synagogue will not be responsible for cards that are lost, stolen or misplaced while in your possession or enroute via U.S. mail.
   
10. You must sign a WAIVER OF RESPONSIBILITY form before card will be mailed to you. These forms will be kept on file, and Etz Hayim Synagogue accepts no responsibility for certificates delivered in this manner.
    

Yes! I'm ready to participate in the Etz Hayim Synagogue Scrip Program

Name

Street Address

City, State, Zip

Phone

I have read and understand the policies and guidelines listed above, and I agree to abide by these policies

___________________________________________________________ _______________________
Signature Date

I will be using my credit card occasionally. Please keep my credit card information on file.

Mastercard or Visa #
Cardholder's Name
Expiration Date
Zip Code

_____________________________________________________________ _____________________
Signature Date

Mail to Etz Hayim Synagogue, PO Box 1600, Derry, NH 03038
or deliver to the synagogue when our Education Program is in session.