Annual Conference Vaccine Certification

Each Annual Conference attendee must complete this form.

You may not complete this on behalf of another attendee.

Please note you only need to fill this form out once. You will not receive confirmation. We will contact anyone we have not received the form from.

Attendee Information

By checking on of the below boxes I affirm that I have been administered the full COVID-19 Vaccine by the start of the 2021 Annual Conference or I am opting to show IMLA a negative COVID-19 test taken within 72 hours of the start of the 2021 Annual Conference (Instructions will be provided as to how to submit your negative test results when the time comes if you select that option).

I have or will have been fully vaccinated* by the start of the Annual Conference.I will submit a negative COVID-19 test that was taken within 72 hours of the Annual Conference starting.

*According to the CDC, an individual is considered fully vaccinated 2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s vaccine.

Address

51 Monroe Street, Suite 404
Rockville, MD 20850

Phone

(202) 466-5424

Fax

(202) 785-0152

Annual Conference Vaccine Certification

Each Annual Conference attendee must complete this form.

You may not complete this on behalf of another attendee.

Address

Phone

Fax

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