Sept. 2019
PNW Employee Wellness Fitness Center Reimbursement Form
To qualify for the $30 reimbursement on your PNW Fitness Center Membership you must:
1. Be a PNW benefits-eligible employee or their spouse AND
2. Have participated in either:
o A Wellness Panel at a PNW Employee Health Screening held on-campus or via a voucher* OR
o An Annual Wellness/Physical Exam with a Primary Care Provider*
*Wellness Panel/Annual Exam must occur in the same calendar year as PNW Fitness Center Membership purchase.
You must complete all fields. Please Print Clearly. A copy of the PNW Fitness Center membership receipt must be attached.
PNW Employee First & Last Name:
Spouse’s First & Last Name (if applicable):
PNW Benefits-eligible Employee
PNW Benefits-eligible Employee Spouse
Fitness Center Membership Purchase Date:
Wellness Panel from PNW Employee Wellness Sponsored Health Screening
Annual Wellness/Physical Visit with Primary Care Provider
Date of Annual Wellness/Physical Visit:
Please submit this form and a copy of the PNW Fitness Center Membership receipt to:
Email: wellness.update@pnw.edu
Campus Mail: Employee Wellness, SWRZ 25
US Mail: Purdue Northwest, Attn: Employee Wellness, 1401 S. US Hwy 421, Westville, IN 46391
In-person drop-off: Schwarz Building (SWRZ), Room 25, 8:00am – 4:30pm CST Monday - Friday
**The reimbursement is paid to the PNW employee in the form of either an automatic payment into their bank accounts
listed for payroll or a paper check mailed to the address on the form. Please allow 2-4 weeks for processing
reimbursement. **
Employee Wellness Use Only:
Yes No
