Phase 1B & 1C Waitlist
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Click which field best describes your eligibility for Phase 1B or 1C:
*
1A Healthcare worker
Teacher/School Staff
Age 70+
Food/agricultural worker
Firefighter, police and correctional staff not in 1-A
Meat processing worker
Manufacturing worker
Grocery worker
US postal service worker
Public transit worker
Essential government worker
Age 65+
Age 16-64 with high risk medical condition(s)
Worker in transportation and logistics
Water and wastewater worker
Food service worker
Shelter and housing worker
Finance worker
IT and communications worker
Worker in energy
Media worker
Public safety and public health worker
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