Exit PRIDE Perks Program Application Question Title * 1. Name of Business Question Title * 2. Contact Name Question Title * 3. Address Question Title * 4. Email Question Title * 5. Phone Number Question Title * 6. Company Website Question Title * 7. Discount *The suggested discount is 15% off of total purchase for Hattiesburg Clinic employees when they present their PRIDE Perks card. Question Title * 8. Date Discount Begins Question Title * 9. Length of Contract*If you choose to terminate your contract before the date listed above, we ask that you give at least 30 days notice so that we can inform our employees. Question Title * 10. Were you referred by a Hattiesburg Clinic employee? If so, what is their name and what department do they work in? Yes/No: Name: Department: Done