COVID-19 Vaccine Registration
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First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Company *
Mobile Number *
Email *
Medical/Health conditions: Employees with any comorbidities like Hypertension, Diabetes, heart issue, stroke, kidney, liver malfunction, respiratory issues, if hospitalized in last 2 years, cancer, multiple disability etc. Will be priority beneficiaries of COVID-19 vaccine irrespective of the age; (If yes, please specify) *
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