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CITY OF PEQUOT LAKES <br />`- 2012 WELLNESS PROGRAM <br />PROOF OF COMPLETION FORM <br />� <br />� <br />Employee Name: <br />2012 Wellness Program Option 1=$10 gift <br />I participated in an online health assessment in 2012 and�i <br />certificate of completion. � <br />I received an annual physical exam from my doctor wi ' <br />months. <br />Please issue the $10 gift card to the following Pequot L � <br />2012 Wellness ] <br />I participated in an online health <br />certiiicate of completion. <br />I received an annual physical ex� <br />months. ` j <br />a r <br />I joined a fitne ' <br />Today's Date: <br />in 2012 and attached <br />Date <br />Completed <br />Date <br />Completed <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 21, 2012. If the form and documentation is complete, the incentive award will <br />be processed. <br />