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BUSINESS MEAL ATTENDEE ROSTER

If NPI is designated in VT, MN, or NJ, Please Notify the Representative

Note for Attendees: The allocated value of meals, along with the information contained on this form, may be reported by Lifeward under certain federal and/or state laws, unless you specifically opt out of the meal.

Name(Required)

First Last

Credential/Designation(Required)

State Of License(Required)

Credential - Other

NPI Number(Required)

Opting Out of Meal(Required)

Yes

Address of Practice or Facility

Facility Name Street Address City State / Province / Region ZIP / Postal Code Country