To begin, please answer the following questions
hereby certify to the best of my knowledge that the information presented is true and accurate under penalty of law. I understand that knowingly providing false information on this form is a class A misdemeanor, and may result in up to a year in jail or a $1,000 fine.*Your proof of eligibility will be checked at the appointment check-in.
As the NYS COVID-19 vaccination eligibility and initiative expands, more information will follow.