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* 1. Company Name

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* 2. Company Address (Please include street address, city & postal code)

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* 3. Authorizing Contact Name

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* 4. Contact Email

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* 5. Contact Phone

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* 6. Title of Post (Company name and discount details)

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* 7. Discount Amount or Offer (indicate if percentage or dollar)

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* 8. Posting information (how you'd like the post to appear on our discount page. Please include your website/key contact details for employees to access the discount/offer). Please note: no posters, only text content)

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* 9. Is Employee ID required to receive discount?

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* 10. End date of offer:

Date
Time

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* 11. By checking the 'agree' box below, I declare that there is no conflict of interest, nor personal gain by VCH sharing this offer with staff:

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