Employer Enrollment Form

Company Information

Contact Information

Enrollment Submission

Please 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

For additional information, contact:

John Lane
Marketing Manager
myWORKPERKS
866-77PERKS ext. 2285