Vaccination Form

Vaccination Form
By submitting this form I am stating that I have had all doses of the COVID-19 vaccine and it has been at least 2 weeks since my last dose. I also certify that I do not currently, nor in the last 10 days, show any symptoms of COVID-19.
The Federal Bureau of Investigation has issued a warning that any American making or purchasing a fake COVID vaccination record card could be punishable by fines or imprisonment up to five years, or both.
Store Number *
Store Email
example@example.com
Sup Email
example@example.com
Name *

First Name Last Name
Date of last shot *

Month Day Year
Date
Clear picture of vaccination card *

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