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* 1. Your Name & Job Title

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* 2. Your Email & Phone Number

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* 3. Company Name & City

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* 4. Company Phone Number

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* 5. Primary Contact (e.g. Supervisor, Manager, Business Owner, etc.)

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* 6. Number of employees at company (*approximately)

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* 7. Tell us about your story!  Describe your “mother-baby friendly” or “family-friendly” program and how the support you have received positively impacted your performance and work environment.

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* 8. Does your program include a lactation room?  If so, describe the space and explain how break times are supported and scheduled.

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* 9. Does your company have written policies that support lactation in the workplace? How are employees educated on these policies?

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* 10. Please tell us more about why you believe your employer should be recognized.

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