PRIDE Perks Program Application Question Title * 1. Name of Business (Required.) Question Title * 2. Contact Name (Required.) Question Title * 3. Address (Required.) Question Title * 4. Email (Required.) Question Title * 5. Phone Number (Required.) Question Title * 6. Company Website (Required.) Question Title * 7. Discount *The suggested discount is 15% off of total purchase for Hattiesburg Clinic employees when they present their PRIDE Perks card. (Required.) Question Title * 8. Date Discount Begins (Required.) Question Title * 9. Length of Contract*If you choose to terminate your contract before the date listed above, we ask that you give at least 30 days notice so that we can inform our employees. (Required.) Question Title * 10. Were you referred by a Hattiesburg Clinic employee? If so, what is their name and what department do they work in? Yes/No: Name: Department: Done
