Employer Enrollment Form Name Would your company like to provide benefits to other employers through the myWORKPERKS program? * Yes NoCompany Information Company Name: * Mailing Address: * City: * State * - Select Province/State -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ====================AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: * Number of Employees (Full-time & part-time): * Contact Information Program Contact: * Title: * Email: * Work Phone: * Enrollment SubmissionPlease attach an excel spreadsheet of all employees that will be enrolled in the program. The spreadsheet must include the following for each employee:• First Name (as it appears on their ID) • Last Name (as it appears on their ID) • Mailing Address • Date of Birth • Home Phone • Email File Upload Submit For additional information, contact:Monique Ferns Marketing Manager myWORKPERKS 866-77PERKS ext. 2285
