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Brentwood Employees proof of vaccination form

Please use this form to submit your proof of vaccination. Valid proof of vaccination includes a photo of your vaccination card or a copy of your New York State Excelsior pass.

Last Name *

First Name *

Employee ID Number *

Please attach a copy of your vaccination record. *

List of Allowed file types

Approvals

A number of approval stages need to be completed before this submission can be accepted.

Acceptance

Appropriate approvers from the Acceptance group will be automatically allocated for this approval stage.