33% of survey complete.

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* 1. 2019 Participation Agreement/Release

Below I designate my decision to participate in the Sumitomo Wiring Systems Inc. Wellness Program. If my designation is YES, I agree to give One Stop Wellness LLC. permission to access/receive downloads from third party vendors for Blood Work data, Health Assessment data, Survey Information, and other data ONLY pertaining to the Sumitomo Wiring Systems Inc. Wellness Program. This information will not be shared with your employer or the associated employer, except in an aggregate format that abides by HIPAA Guidelines

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. Work Site Location

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

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* 9. 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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