UTEAP - UT Employee Assistance Program - Employer Proposal Request Form

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(*) denotes required information.

*First Name:

*Last Name:

Title:

Organization:

*Phone:

*Email:

Website

*Address 1:

Address 2:

*City:

*State:

*Zip:

Industry

*Number of Employees:

Locations of Employees:

Do you have employees that are covered under Department of Transportation (DOT) regulations?

*Does your organization currently have an EAP?

If Yes, name of current EAP vendor:

* Number of counseling sessions you would like quoted:

Proposed Start Date of Services:

Would you like to be contacted before we send proposal?

Comments/Questions:

*Validate Image:
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