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* 1. Department

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* 2. First Name (as it appears on your Driver's License or Govt Issued ID)

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* 3. Last Name (as it appears on your Driver's License or Govt Issued ID)

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* 4. 5-Digit Employee ID

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* 5. You have been identified as potentially vaccine eligible by the State Health Department for an upcoming phase. Do you want to participate in the voluntary vaccination program? If yes, you authorize the City to provide your contact information to the State, if requested for registration.

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