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Please complete Sections A and B of this form as follows:
September 29th, 2020
  • Filed
    September 29th, 2020

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.

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Please complete Sections A and B of this form as follows:
September 29th, 2020
  • Filed
    September 29th, 2020

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location (Location) covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 29th, 2020
  • Filed
    September 29th, 2020

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location (Location) covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 1st, 2017
  • Filed
    September 1st, 2017

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 1st, 2017
  • Filed
    September 1st, 2017

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 1st, 2017
  • Filed
    September 1st, 2017

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location (Location) covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 1st, 2017
  • Filed
    September 1st, 2017

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 1st, 2017
  • Filed
    September 1st, 2017

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location covered under the Organization listed in Section A.

Please complete Sections A and B of this form as follows:
September 1st, 2017
  • Filed
    September 1st, 2017

The Centers for Disease Control and Prevention (CDC) greatly appreciates your organization’s (Organization) participation in the CDC COVID-19 Vaccination Program. Your Organization’s chief medical officer (or equivalent) and chief executive officer (or chief fiduciary)—collectively, Responsible Officers—must complete and sign the CDC COVID-19 Vaccination Program Provider Requirements and Legal Agreement (Section A). In addition, the CDC COVID-19 Vaccination Program Provider Profile Information (Section B) must be completed for each vaccination location (Location) covered under the Organization listed in Section A.

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