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* 1. 2019 Participation Agreement/Release

FYI...  EVERY TIME YOU CLICK ON THE LINK TO THIS AGREEMENT, THE SYSTEM THINKS YOU ARE A NEW PERSON SIGNING UP.  IF YOU HAVE ALREADY FILLED THIS OUT AND GOT A THANK YOU PAGE, THERE IS NO NEED TO FILL THIS OUT AGAIN. If you would still like further confirmation e-mail onestopwellness@epbnet.com.  Include your name and ID# and we will formally confirm that the system has captured your information.  Also, if you would like a copy of what you have signed/designated we will be happy to provide that.

Below I designate my decision to participate in the Sumitomo Electric Carbide Manufacturing Inc. Wellness Program. 

Please mark your designation (Yes or No) below.

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* 2. First Name

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* 3. Middle Name

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* 4. Last Name

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* 5. Date of Birth

Date of Birth

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* 6. Male or Female

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* 7. Contact Information (This information will not be used for any form of solicitation)

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* 8. Electronic Signature:

I understand that by clicking "I Confirm" below I am stating that the information belongs to me and is correct. I also understand that this IS MY ELECTRONIC SIGNATURE that will designate my choice on the Agreement/Release Form (above).

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