VACCINE incentive app — Village of Solomon

vaccine incentive application

ELIGIBILITY

• You have received at least one dose of COVID-19 vaccine as specified by the FDA:

• If you are receiving the Pfizer or Moderna COVID-19 vaccine, you have received at least one dose of the COVID-19 vaccine

• If you are receiving the Johnson & Johnson COVID-19 vaccine, you have received the one required dose of the COVID-19 vaccine

Name

First Name

Last Name

Enrollment #

Physical Address

Mailing Address

Phone Number

Name of Vaccine:

I, hereby certify that all information is accurate and true. By signing this application, I understand I am entering a drawing for the Village of Solomon Vaccination Incentive Program and am not entitled to a prize. I also acknowledge that I have provided the tribal office with proof of my enrollment and my vaccination record/card by email, U.S. Mail or the drop-box at the office.

Signature

Date