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CITY OF PEQUOT LAKES <br /> 2015 WELLNESS PROGRAM <br /> PROOF OF COMPLETION FORM <br /> Employee Name: <br /> Date <br /> 2015 Wellness Program Option 1 = $10 gift card Completed <br /> I participated in an online health assessment in 2015 and attached a <br /> certificate of completion. <br /> I received an annual physical exam from my doctor within the last 15 <br /> months. <br /> Please issue the $10 gift card to the following Pequot Lakes business: <br /> - or- <br /> Date <br /> 2015 Wellness Program Option 2 =$100 Completed <br /> I participated in an online health assessment in 2015 and attached a <br /> certificate of completion. <br /> I received an annual physical exam from my doctor within the last 15 <br /> months. <br /> I joined a fitness club and remain an active member in 2015 and attached <br /> documentation of my membership. <br /> Employee's Signature: <br /> Today's Date: <br /> This form must be completed and submitted along with documentation to Nancy <br /> Malecha. Completed forms can be submitted at any time during the year but no later than <br /> December 18, 2015. If the form and documentation is complete, the incentive award will <br /> be processed. <br />