欧博abgFree Vaccine Exemption Form Template & FA
I, , personally appeared before the notary public and swear or affirm as follows:
. I am an employee of , located at , , , .
. I understand that the Department of Public Health has determined:
a. that the required vaccinations are necessary to prevent the spread of dangerous diseases among the people of this state;
b. that the required vaccinations are safe;
c. that a person who does not receive the required vaccinations is at risk of contracting those diseases; and
d. that a person who does not receive the required vaccinations is at risk of spreading these diseases to other persons
. I understand that, my exemption notwithstanding, I may be prohibited from working in person or subject to other accommodations during an epidemic or pandemic.
By: ___________________________________ Date: __________________
STATE OF ,
DISTRICT OF COLUMBIA, ss:
The foregoing instrument was acknowledged before me this _____ day of ____________________, ______ by , who is personally known to me or who has produced ________________________________ as identification.
Before me, a Notary Public (or justice of the peace) in and for said county, personally appeared the above named , ________________________________, and ________________________________, who acknowledged that they did sign the foregoing instrument, and that the same is their free act and deed. In testimony whereof, I have hereunto subscribed my name at ________________________________, this _____ day of ____________________, ______.
The foregoing instrument was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _____ day of ____________________, ______ by , who is personally known to me or who has produced ________________________________ as identification.
This instrument was acknowledged before me on this _____ day of ____________________, ______ by .
Subscribed, sworn to and acknowledged before me by , the Employee, this ________ day of _____________.
On this _____ day of ____________________, ______, before me personally appeared , to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he/she executed same as his/her free act and deed.
On this _____ day of ____________________, ______, before me, ________________________________, personally appeared , known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same as for the purposes therein contained.
On this _____ day of ____________________, ______, before me, the undersigned, Notary Public for the State of Vermont, personally appeared , to me known (or to me proved) to be the identical person named in and who executed the above affidavit, and acknowledged that such person executed it as such person's voluntary act and deed.
The foregoing instrument was acknowledged before me this _____ day of ____________________, ______, by .
In witness whereof, I hereunto set my hand and official seal.
Signature of person taking acknowledgment
Notary Public
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Name typed, printed, or stamped
My commission expires _____________
Notary Address:
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