HBRs and Wellness Chairs Register

* Required entries
First Name:*
Last Name:*
Title:*
Position Role:*
  Health Benefits Representative (HBR)   HR Director (HRD)
  Chairperson of Worksite Wellness Committee
  Other: (please specify)
If you are an HBR, do you work in:
  Benefits/Human Resources    Payroll/Accounting
  Other: (please specifiy)
Do you work for a:*
  School    State Agency    University    Community College
  Other: (please specifiy)
Workplace Name:*
 
If working for a State Agency, please specify the division if applicable:
 
Email:*
ex. user@email.com (This will be your login)
Phone:* ex. nnn-nnn-nnnn
Fax: ex. nnn-nnn-nnnn
Address:*
City:*
State:*
Zip:* ex. nnnnn OR nnnnn-nnnn