Company Name:
A Company Name is required.
Main Business Address:
A Main Business Address is required.
Main Business Phone Number:
A Business Phone Number is required.
Main Business Fax Number:
A Main Business Fax Number is required.
Business Locations:
Business Locations required.
Company Web Site Address:
Company Web Site Address is required.
Splash Page:
Splash Page is required.
Contact Person:
A Contact Person is required.
Contact Phone Number:
A Contact Phone Number is required.
Contact Email Address:
A Contact Email Address is required.
Industry:
A Industry is required.
Services or Products Offered:
Services or Products Offered are required.
Discount Details:
Discount Details are required.
Does this offer have an end date?
If yes, end date:
Licensing, certification, or other requirements (please list all information):
Requirements are required.
Discount offered to all UNC employees?
If No, list all requested limitations or restrictions on the discount offer:
I acknowledge that I have read the Work_Life Employee Discount Program policy, the business is agreeing to all conditions and policies, and is attesting that all information provided on this form is factual. For businesses owned or operated by a State of Colorado employee, by sending this application, the employee is agreeing to comply with all rules and regulations concerning conflict of interest and outside employment.
Yes
You must acknowledge that all information is factual and correct to submit application.
Name of person completing application:
Name of person completing application is required.