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City <br />E <br />Pre-Authorization Form <br />Wage Incentive <br />Program <br />for the Whole Health Component <br />Use this form to request an activity that is not listed in Appendix B of the policy. <br />This form is to be used PRIOR to participating in the activity. Following your participation in <br />the activity, a Validation Form will be required to receive credit for the event. <br />Your name: (please prznt) <br />Date submitted: <br />Check which categoryT this event would apply toward. <br />❑ Education ❑ Wellness ❑ Community Service <br />What would yTou like to do? <br />How does this Yelate to the category selected above? <br />Please attach an�r documentation that would help to explain this item and how it relates to yrour <br />selected category. (ex. program flyer) <br />❑ Your requested activinT is approved to be used to`vard the categoryT yTou have selected. <br />❑ Your Yequested activity is approved but is to be used foY the categoryr circled above. <br />❑ Your requested activity is not approved for the follo`ving reason: <br />Human Resources Manager <br />Date <br />Kiver <br />