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* 1. Name of Business

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* 2. Contact Name

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* 3. Address

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* 4. Email

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* 5. Phone Number

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* 6. Company Website

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* 7. Discount 
*The suggested discount is 15% off of total purchase for Hattiesburg Clinic employees when they present their PRIDE Perks card.

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* 8. Date Discount Begins

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* 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.

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* 10. Were you referred by a Hattiesburg Clinic employee? If so, what is their name and what department do they work in?

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