EXCEL STAFFING SERVICES, INC.

EMPLOYEE SERVICE APPLICATION:

*Note: This application is kept confidential and is sent directly to our HR's email.

Full Name: Tax ID / SSN #:

Your Email:

Applying as (click one):

Phone, Primary:
Phone, Alternate:
Date of Birth: *
Mailing Address:

Are you a U.S. Citizen or legally able to work in the United States?

U.S. Social Security Card:

Social Security Card

Driver's License/Picture ID:

Drivers License

Have you ever been an employee with us?



PROFESSIONAL INFORMATION:

STATE(S) WHERE LICENSED LICENSE #

*Please let us know if you are licensed in any other states. This includes compact nurse licenses.

CPR CERTIFICATION *Note:(Nurses must be CPR certified to work with us.)

EXPIRATION DATE

OTHER MEDICAL CERTIFICATION(S):

PHOTO: Please upload a photo of your TB Test (Must be within a year from this date):

TB Test

EDUCATION:

HIGH SCHOOL/GED DATE GRADUATED:

COLLEGE/TECH SCHOOL DATE GRADUATED

AVAILABILITY:

SHIFT PREFERENCE

12 HOURS?



EMPLOYMENT HISTORY:

MUST BE FILLED OUT COMPLETELY

Employer 1 (Most Recent)

COMPANY NAME PHONE
COMPLETE ADDRESS :
JOB TITLE SUPERVISOR
REASON FOR LEAVING
Employment Dates: to


Employer 2

COMPANY NAME PHONE
COMPLETE ADDRESS :
JOB TITLE SUPERVISOR
REASON FOR LEAVING
Employment Dates: to


Employer 3

COMPANY NAME PHONE
COMPLETE ADDRESS :
JOB TITLE SUPERVISOR
REASON FOR LEAVING
Employment Dates: to

VERIFICATION

The information on this application is accurate and subject to verification. I understand that any misleading or incorrect statements may render this application void. Special needs, shift variances, travel and other requirements determine what I will invoice Excel (per time slip/invoice) at a negotiated shift rate.




OSHA REGULATIONS AND GUIDELINES


In accordance with OSHA regulations, each contractor must review the Blood Borne Pathogen, Hazard Communications, Emergency Action Plan, Fire Prevention and Escape Routes.

Excel has notified each facility that they are responsible and must review their facility’s specific plan with each contractor that works in that facility.

I acknowledge I received Blood Borne Pathogen (BBP) training at the time I was hired by Excel Staffing Service, INC. (Excel). I am also subject to BBP training at all facilities I am placed to work. If I need further training Excel and the facility will provide further instruction.

Please review all enclosed material, sign and date this sheet.

I, have reviewed and understand the presented material as stated. I have been given the opportunity to clarify any questions that I may have.




HEPATITIS B VIRUS VACCINE CONSENT OR DECLINATION

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus infection (HBV). At this time I choose the following:

Check one, then sign at the bottom.

I understand that I will be reimbursed for the cost of any shots in the Hep B series taken during the time I am working through Excel. In addition, I agree to request reimbursement while I am still actively accepting work and understand my request may be denied if it is made after I am terminated or inactivated for any reason.




AUTHORITY FOR RELEASE OF INFORMATION

I authorize Excel Staffing Services, Inc. to perform a criminal history record information check in connection with my work, and to share the information with any / all facilities where I will accept work when required.

Full Legal Name (Current):
Middle Name if Applicable:
Maiden Name if Applicable:

Tax ID/SS#
Date of Birth:

Zip Code in which you currently live:

I hereby release said agency and persons from any and all liability, which may be incurred as a result of furnishing such information. In addition, as an Employee, I will submit a $20.00 money order to cover the cost of this criminal background check to be done. MS Residents will have to send in a $50.00 money order along with a fingerprint card for a federal background check or a MS Fingerprint Clearance letter dated within the last two years as required by the state.




NOTIFICATION AND RELEASE

This is for Excel Staffing to run your criminal background.

Company Name: Excel Staffing Service - Greensboro // Sales Representative Colbey Stricikland
Access ID - BeeCheck ID 0000111712283500 - CAC Code XC35

The information contained in my application for employment with (company name) Excel Staffing Service - Greensboro (hereinafter, "The Company") is true to the best of my knowledge and belief. I understand that any misrepresentation or false statement made by me in connection with the application or any related documents which is deemed material by The Company shall result in The Company not employing me or, if employed, terminating my employment. I understand and agree that all inforination furnished in my application and all attachments may be verified by The Company or its authorized rep-resentative. I hereby authorize all individuals and organizations named or referred to in my application and any law enforcement organization to give The Company all information relative to such verification and hereby release such individuals, organizations and The Company from any and all liability for any claim or damage resulting therefrom. I hereby acknowledge that I have been informed by The Company that The Company may seek to 'obtain a consumer report and/or investiga-tive report that will include personal information regarding me, including but not limited to, educational history, work references, driving record, drug testing and criminal convictions or arrest records if allowed, in order to assist The Company in making certain employment decisions. I further acknowledge notification by The Company that reports may be provided to The Company by other firms subcontracted for that purpose. I, my heirs, assigns and legal representatives, hereby release and fully discharge The Company, its parent and affiliated companies'and the respective officers, directors, shareholders, employees, agents of each, including subcon-tractors, from any and all claims, monetary or otherwise, that I may have against The Company, its parent, affiliates or subcontractors, arising out of the making, or use of, either a consumer report and/or investigative report, including any errors or omissions contained or omitted from such reports or investigations. The Company agrees to inform you if an employment decision has been influenced by Information contained in a consumer report, made at our request by Castle Branch Inc. You may obtain a free copy of the report within sixty days by calling Castle Branch Inc. collect at (910) 815-3880 or toll free at (888) 520-0520. The Company will make available to you "A Summary of Your Rights Under The Fair Credit Reporting Act."

PLEASE FILL OUT ALL PARTS

Name (First, Middle, Last) Date of Birth *
Maiden Name or "AKA" (First, Middle, Last):
Dates Used (yr) from to
Social Security# Driver's License #: State:

Your Email (We'll send you a copy of this doc):

Current and previous address(es). PROVIDE ALL ADDRESSES FOR PREVIOUS 7 YEARS

Current Address: Unit # Zip:
From to (Current)

Previous Address: Unit # Zip:
From to

Previous Address: Unit # Zip:
From to

Previous Address: Unit # Zip:
From to



(Applicants do not fill out this portion.)

Contact: Brenda Baliel

Email: hr@excelnursing.com

Phone: 1-800-883-9235

Fax: 336-291-1011

"NW-DATABASE" format="Vertical" options="NW-Database"]

NW-Database

Residency History



CONSENT FOR DRUG SCREENING

I am aware that as a contract laborer, pre-employment drug testing is not necessary but that it may be requested that I voluntarily consent to a drug screening at my own expense. I hereby give my consent for this screening. Excel Staffing will give site location of where this service may be performed. I am also aware that I will be limited to the work offered if I do not have the test done before my shift is confirmed.




DISCLAIMER

In the signing of this document, I acknowledge and agree that I am contracted to facilities by Excel Staffing Service, Inc. I also understand that I am not an employee of the facility and that I have no legal rights to any benefits provided by the facility to its employees.

I further agree that I will not make any claims against said facilities for any wages or benefits including Worker’s Compensation claims.





REFERENCE REQUEST #1

Professional Reference:

Company Name Supervisor Name:

Supervisor Phone:

I hereby authorize the employer named above to provide any requested information to Excel Staffing Services, Inc. and release them from all liabilities in responding to inquiries in connection with my application.



TO BE COMPLETED BY EXCEL STAFFING

(Applicants do not fill out this portion.)

Dates of Employment: From____________ To:______________

Position Held:___________________________________________________

Reason for Leaving:______________________________________________



REFERENCE REQUEST #2

Professional Reference:

Company Name Supervisor Name:

Supervisor Phone:

I hereby authorize the employer named above to provide any requested information to Excel Staffing Services, Inc. and release them from all liabilities in responding to inquiries in connection with my application.



TO BE COMPLETED BY EXCEL STAFFING

(Applicants do not fill out this portion.)

Dates of Employment: From____________ To:______________

Position Held:___________________________________________________

Reason for Leaving:______________________________________________



Temporary Employee Notice

Excel Staffing is a temporary help company, which provides temporary help employees to various nursing facilities. As a temporary employee hired as such with our company, you are required to contact our office after completion of your assignment.

CALLING THE ANSWERING SERVICES IS NOT CONSIDERED CONTACTING OUR OFFICE.


You must contact our office and talk to our staffing professional to let us know you have completed your assignment.

Failure to contact our office for reassignment will mean that you have quit work without good cause. This may make you ineligible for benefits, including but not limited to unemployment benefits.




Paper Check Processing Fee

Effective December 1, 2010 there will be a $5.00 check-processing fee deducted from all paper payroll checks that are issued.

I am aware of the non-refundable check-processing fee which would be deducted from all payroll checks that are issued to me.

I also understand there are no fees if I receive my payroll via direct deposit.




AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS
(ACH CREDITS)

I (WE) hereby authorize EXCEL STAFFING SERVICE, INC. hereinafter called COMPANY, To initiate credit entries and/or correction entries to my / our Account (select one) indicated below at the depository named below, hereinafter called DEPOSITORY, to credit the same to such account.

Optional: Photo of Deposit Slip:

DepositSlip

Bank Name:


Routing / Transit Number (First 9 Numbers on Left of Check)

Account Number (To the Right of Routing Number on Check)

This authorization is to remain in full force until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY reasonable opportunity to act upon it.




EMPLOYMENT AGREEMENT

This Employment Agreement (the “Agreement”) is made and entered into this (hereinafter referred to as the “Effective Date”) by and between Excel Staffing Service, Inc., a North Carolina corporation (the “Company”), and (the “Employee”). The Company and the Employee are collectively referred to as the “Parties” in this Agreement.

WITNESSETH

WHEREAS, the Company has offered the Employee employment with the Company.

WHEREAS, prior to the offer of employment and prior to actually beginning work with the Company, Employee acknowledged and agreed that Employee would, as a condition of employment, sign this Agreement, containing the non-disclosure of confidential information and arbitration provisions set forth herein.

WHEREAS, as a condition precedent to the offer of employment and in consideration of the Company employing Employee; compensating Employee; providing Employee with certain employee related benefits; training Employee; and other good and valuable consideration, the receipt, adequacy, and sufficiency of which are hereby acknowledged and accepted, Employee has agreed to enter into this Agreement and has agreed to the provisions contained herein.

NOW, THEREFORE, for good and valuable consideration, the receipt, adequacy, and sufficiency of which are hereby expressly acknowledged and accepted, the Company and Employee, intending to be legally bound, hereby agree as follows:

ARTICLE 1

EMPLOYMENT

1.1 Employment At-Will. Both the Company and Employee acknowledge that the Employee’s employment is “at will,” and may be terminated by either party at any time, with or without reason, by giving notice to the other party. Nothing in this Agreement or in any written or oral communication constitutes an offer or agreement by the Company to employ Employee for any particular length of time nor by Employee to remain employed for any particular length of time.

1.2 Employee Duties and Responsibilities. Employee agrees to perform all duties and responsibilities assigned by the Company in a competent, diligent, and professional manner and to help advance and render profitable the interests, business, and goodwill of the Company.

1.3 Company Rules, Regulations, and Policies. Employee agrees, during his or her employment, to adhere to all rules, regulations, and policies that have been or that hereafter may be established by the Company for the conduct of its employees.

ARTICLE 2

COMPENSATION

2.1 Compensation. For all services rendered by Employee, in whatever capacity, during employment under this Agreement, Employee will be paid in accordance with the Company’s normal payroll schedules and policies (and subject to any and all applicable federal, state, and local taxes and other statutory withholdings, payroll deductions, and other deductions allowed or required by law). Employee acknowledges that Employee’s compensation is subject to change at any time at the Company’s discretion.

2.2 Vacation. During Employee’s employment under this Agreement, Employee will be eligible to accrue vacation time such as is allowed for other similar employees of Company pursuant to the Company’s vacation policies then in effect. Any such vacation time shall accrue and shall be taken in accordance with the current Company vacation policies.

2.3 Other Benefits. Employee, if otherwise eligible, will be allowed to participate, following any applicable waiting periods, in Company-sponsored group benefit plans. Eligibility for participation in any Company-sponsored group benefit plans is determined in accordance with the terms of each plan, and each plan is subject to change in the Company’s discretion.

ARTICLE 3

CONFIDENTIAL INFORMATION & COMPANY PROPERTY

3.1 Non-Disclosure of Confidential Information. Employee recognizes the interest of the Company in maintaining the confidential nature of its proprietary and other business and commercial information. In connection therewith, Employee covenants that during the Employee’s employment with the Company and after employment has ended, Employee shall not, directly or indirectly, publish, disclose or use for the Employee’s own benefit, or for the benefit of any business or entity other than the Company, data or information relating to the Company (whether constituting a trade secret or not), which is or has been disclosed to Employee or of which Employee became or becomes aware as a consequence of or through Employee’s relationship with the Company and which has value to the Company and is not generally known to the Company’s competitors (the “Confidential Information”). Confidential Information includes, but is not limited to, names, contacts, addresses, email addresses, and phone numbers of the Company’s Clients and information regarding Clients’ needs, projects, pricing, services, fee arrangements, costs, profits, financial data, method of doing business, techniques, developments, development plans, training materials, standard operating procedures, software code, improvements, inventions, and other business information relating to the Company that is not generally known. The Confidential Information shall not include any data or information that is voluntarily disclosed by the Company (except where such public disclosure has been made by Employee without authorization) or that has been independently developed or disclosed by others, or that otherwise enters the public domain through lawful means. Employee acknowledges that all Confidential Information and all embodiments thereof shall be and remain the sole property of the Company, and Employee shall, upon request of the Company, deliver to the Company all Confidential Information and embodiments thereof, and all records, documents and other property of or pertaining to the Company, then in Employee’s possession or control and shall not retain any copy or extraction thereof.

3.2 Return of Company Materials. Employee agrees that, upon the termination of his or her employment with the Company for any reason, Employee will return to the Company’s possession and control, all records, documents, files, price lists, customer lists, drawings, computer disks, brochures, pictures, videotapes, and other data compilations containing information of the Company of any type or description (including all copies thereof) which are then under Employee’s control or in Employee’s possession, whether developed and/or compiled by the Company, Employee, or others. Employee also agrees that Employee will sign, upon the termination of his or her employment for any reason, an affirmative representation that Employee has returned all such materials.

ARTICLE 4

CERTAIN REMEDIES

4.1 Injunctive Relief. Employee acknowledges that any breach of this Agreement, including without limitation Article 3 hereof, will cause immediate and irreparable harm to the Company and that the resulting damages will be exceedingly difficult to measure in full. Therefore, the Employee acknowledges that payment of damages to the Company in an action at law for breach of this Agreement would not adequately compensate the Company for the harm it suffered. The Employee and the Company therefore agree that, in addition to all of the remedies provided at law or in equity, this Agreement may be enforced by means of injunctive relief, including but not limited to a temporary restraining order and injunctions, and that all other available remedies at law or in equity, including but not limited to money damages, may be pursued for breach of this Agreement.

ARTICLE 5

NO CONFLICTING AGREEMENTS

5.1 No Conflicting Agreements. Employee agrees not to disclose to the Company or induce the Company to use any confidential or proprietary information belonging to any of Employee’s previous employers, to any clients of Employee’s former employers, or to others. Further, Employee represents and warrants to the Company that the performance of his or her job duties as may be assigned to him or her from time to time by the Company shall not violate, cause the breach of, or conflict with any prior agreement, contract, or understanding between him or her and any third party or otherwise violate any confidence of another, including but not limited to, any agreement prohibiting him or her from competing with such third party. In the event that the representation and warranty made by Employee above is not true, accurate, or correct, Employee agrees that he or she will indemnify and hold harmless the Company and its successors and assigns against any loss, damage, claim, or expense (including reasonable attorneys’ fees based on the customary hourly rates then charged for their services) incurred by the Company or its successors or assigns that arise out of or are related to the breach of his or her representation and warranty to the Company as set forth above. The failure of either party at any time or times to require performance of any provision hereof shall in no manner affect the right, at a later time, to enforce such provision.

ARTICLE 6

ARBITRATION

6.1 Agreement to Arbitrate Disputes. Any controversy or claim arising out of the Employee’s employment with the Company and/or termination of employment with the Company shall be settled by arbitration administered by the American Arbitration Association under the Employment Arbitration Rules and Mediation Procedures, as amended and in effect at the time the arbitration is initiated (the “Rules”), and judgment upon the award rendered by the arbitrator may be entered in any court having jurisdiction thereof. By way of example, such controversies and claims include those under federal, state, and local statutory or common law, such as claims for breach of contract, wrongful discharge, negligent retention, libel, slander, emotional distress and/or claims under Title VII of the Civil Rights Act of l964, as amended, 42 U.S.C. § 2000e et seq.; the Civil Rights Act of 1991, as amended, 42 U.S.C. § 1981a et seq. (“CRA of 1991”); 42 U.S.C. § 1981 (“Civil Rights Act of 1866”); the Fair Labor Standards Act of 1938, as amended, 29 U.S.C. § 201 et seq.; the Equal Pay Act of 1963, 29 U.S.C. § 206(d)(1); the Americans with Disabilities Act, 42 U.S.C. § 12101 et seq.; the Rehabilitation Act of 1973, 29 U.S.C.A. § 794; the Family and Medical Leave Act of 1993, 29 U.S.C. § 2601 et seq.; the Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. § 621 et seq.; the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq. (“ERISA”); the Lilly Ledbetter Fair Pay Act; the Occupational Safety and Health Act; the North Carolina Wage and Hour Act; the North Carolina Persons with Disabilities Protection Act, N.C. Gen Stat. § 168A-1 et seq.; the North Carolina Equal Employment Practices Act, § 143-422.1 et seq.; and the North Carolina Retaliatory Employment Discrimination Act, as well as any state, local, or federal employment discrimination laws.

NOTICE: THE EMPLOYEE AND THE COMPANY UNDERSTAND THAT THEY WOULD HAVE HAD A RIGHT OR OPPORTUNITY TO LITIGATE DISPUTES THROUGH A COURT AND HAVE A JUDGE OR JURY DECIDE THEIR DISPUTES BUT HAVE AGREED INSTEAD TO RESOLVE DISPUTES THROUGH BINDING ARBITRATION, HAVE ELECTED ARBITRATION AS THEIR EXCLUSIVE FORUM, AND WAIVE ANY RIGHT TO TRIAL BY JURY IN A COURT OF LAW TO RESOLVE ANY DISPUTE.

Any arbitration initated under the terms of this Agreement shall be held in Guilford County, North Carolina, and shall be conducted and ruled upon by a single neutral Arbitrator selected using the listing process set out under the Rules. A copy of the most recent version of the Rules, as amended from time to time by the American Arbitration Association, is available from the Company for review upon request. The Arbitrator’s decision, including the amount of any award, shall be final and binding upon the Parties. Together with the decision, the Arbitrator shall provide a written explanation of the decision and of any award. Any judgment upon an award made by the Arbitrator may be entered in any state or federal court having competent jurisdiction. All remedies available to the Employee or the Company in a court of law shall be available through arbitration unless they conflict with Section 6.2 of this Agreement.

The costs of the arbitration (filing fee, administrative fee, if any, and the Arbitrator’s fee) shall be paid by the Company, however, the Employee and the Company will each pay his or her, or its own attorney’s fees incurred in prosecuting or defending the arbitration. Nothing in this arbitration provision shall prevent the Arbitrator from awarding the costs of the arbitration and/or attorney’s fees to a prevailing party as allowed by law or by the Rules.

Nothing in this Agreement precludes the Employee or the Company from filing a complaint with a federal, state or other governmental administrative agency.

6.2 One-Year Limitation Period for Initiation of Arbitration. Any arbitration initiated under the terms of this Agreement must be initiated with the American Arbitration Association within one (1) year following the date of the incident complained of. If the applicable statute of limitations is less than one (1) year, no demand or request for arbitration shall be made after the date when such dispute would be barred by the applicable statute of limitations. Additionally, no demand or request for arbitration shall be made after the administrative deadline for filing such a claim has expired.

6.3 Agreement Not to Bring, Join, or Participate in Class or Collective Actions. To the extent permitted by law, the Employee agrees that he or she will not bring, join, or participate in any class action lawsuits, collective action lawsuits, class arbitrations, or collective action arbitrations as to any claim, disputes, or controversy the Employee may have against the Company or any of the Company’s owners, managers, officers, directors, employees, or assigns. The Employee agrees to the entry of injunctive relief to stop such a class action lawsuit, collective action lawsuit, class arbitration, or collective action arbitration to remove the Employee as a participant in such lawsuit or arbitration. The Employee also agrees to pay the attorneys’ fees and court costs the Company incurs in seeking such relief. This Agreement does not constitute a waiver of any of the Employee’s rights and remedies to pursue a claim individually (and not as a class) in binding arbitration as provided above in Articles 6.1 and 6.2.

ARTICLE 7

MISCELLANEOUS

7.1 Controlling Law. This Agreement shall be construed, interpreted, and enforced both as to substance and remedies, in accordance with the laws of the State of North Carolina.

7.2 Entire Agreement. This Agreement contains the entire agreement and understanding of the Parties with respect to the subject matter hereof. This Agreement shall not be modified or amended except by further written documents signed by both the Employee and the Company.

7.3 Severability. If any section, subsection, provision, term, paragraph, subparagraph or subpart of this Agreement shall, for any reason, be ordered or adjudged by any court of competent jurisdiction to be invalid or unenforceable, such judgment shall not affect, impair or invalidate the remainder of this Agreement but shall be confined in its operation to the provision or provisions regarding which such judgment shall have been rendered.

If any section, subsection, provision, term, paragraph, subparagraph or subpart of this Agreement is ordered or adjudged by a Court of competent jurisdiction to be invalid, unenforceable or unreasonable, such provision shall be reformed as provided for by law, and/or shall be deemed amended, to apply as to such maximum time, scope and territory or to such other extent as the adjudicating authority may determine or indicate to be reasonable, such amendment to apply only with respect to the operation of such provisions in the particular jurisdiction in which such adjudication is made.

7.4 Non-Waiver. No act or representation by either party shall constitute a waiver of any right under this Agreement, other than a writing expressly waiving a right. No waiver of any term or condition of this Agreement by any party shall be deemed a continuing or further waiver of the same term or condition or a waiver of any other term or condition of this Agreement.

7.5 Assignment. The rights and obligations of the Company under this Agreement may be assigned and delegated to any successor to or assignee of the Company’s operations. The rights and obligations of Employee under this Agreement are personal and may not be assigned or delegated.

7.6 Opportunity to Review. Employee acknowledges that he or she has read and understands the provisions of this Agreement, has had the opportunity to review the Agreement with legal counsel prior to execution of the Agreement, and has elected to execute the Agreement based on his or her own free will and without any promise having been made to the Employee other than the promises by the Company set forth herein.

IN WITNESS WHEREOF, the Parties hereto have executed this Agreement as of the date herein first above written.

NOTICE: THE EMPLOYEE ACKNOWLEDGES THAT HE OR SHE HAS READ THIS AGREEMENT AND UNDERSTANDS THAT THIS AGREEMENT INCLUDES AN AGREEMENT TO ARBITRATE DISPUTES (ARTICLE 6.1), A MAXIMUM OF A ONE-YEAR LIMITATION PERIOD FOR INITIATION OF ARBITRATION (ARTICLE 6.2), AND A CLASS AND COLLECTIVE ACTION WAIVER (ARTICLE 6.3), ALL OF WHICH MAY BE ENFORCED BY THE PARTIES.





DON'T FORGET!

$50 - $$$$ EASY MONEY $$$$

WE JUST WANTED TO REMIND YOU TO KEEP THOSE REFERRALS COMING! FOR EVERY NURSE OR CNA YOU REFER WHO APPLIES,WORKS, AND HAS BEEN PAID FOR 40 HOURS, YOU WILL RECEIVE A $50 BONUS.

THESE BONUSES ARE UNLIMITED!

BE SURE TO HAVE THE PERSON YOU ARE REFERRING TO WRITE YOUR NAME DOWN ON THEIR APPLICATION.

FOR MORE INFORMATION OR TO CHECK ON A REFERRAL, CALL THE RECRUITING DEPARTMENT AT 1-800-883-9235 EXT 320.

=============

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Friend / Colleague 1

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Phone:

Friend / Colleague 2

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This coupon must be attached to your referral’s application in order to qualify for this bonus.


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