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Reason for Freeze (EFT only) ---Work relatedMedical relatedPersonal
15 DAY FREEZE REQUEST NOTICE*: By checking this box and clicking the "Submit" button on this page, I acknowledge that the freeze request can take up to 15 (fifteen) days to be processed. I further acknowledge that if my next scheduled billing date is less than 15 days from the submission date of this form, I MAY be billed as per terms outlined in my contract.
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