EMPLOYEE REGISTRATION Form

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Employee Details
Name *	Gender *	Year of Birth *	Mobile No. *	Preferred Vaccination Center *	Cowin Registration No. *	Preferred Date*	Preferred Time*

Declaration *

I hereby declare that the employee / list of employees which I have submitted for Covid vaccination is / are working in my institution and they belong to the category of Frontline worker in Covid care. I also declare that the above employee/ employees belong to the age group between 18 years and 44 years.
"I am aware that providing false information is an offence and that I am personally responsible for the above declared information".

:: Request for Vaccination ::

Declaration *