First Responder Vaccine Prioritization Submission

Organization's Information:
Organization's Name*
Organization's Mailing Address*
Street Address Address Line 2 City State ZIP Code
Authorizing Official's Information
Is the person submitting this form also the authorizing official?*
Aurthorizing Official's Name*
First Last
Authorizing Official's Title*
Authorizing Official's Phone*
Authorizing Official's Email*
Enter Email Confirm Email
Submitter's Information
Your Name*
First Last
Your Title*
Your Phone*
Your Email*
Enter Email Confirm Email
Vaccine Prioritization Worksheet(s)
Upload Vaccine Prioritization Worksheet(s) *
Must be uploaded as an .xlsx or .xls
Drop files here or

Accepted file types: xls, xlsx, Max. file size: 1 GB.
Certification and Submission
Statement of Acknowledgement*
By writing my full name below (as an electronic signature), selecting today's date and clicking the submit button, I am attesting that the information provided in this form and the attachments are true and accurate to the best of my ability. I also acknowledge that failure to provide accurate and/or misleading information may be grounds for disqualification. Lastly, I understand that everything submitted is subject to audit and review.
Certification Date*
MM slash DD slash YYYY

Organization's Information: