COVID-19 Vaccine Mandate Inquiry Form
Please provide the following information if you are requesting legal guidance regarding how to request a religious exemption from a COVID-19 vaccine mandate.
Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Name of the business or institution requiring COVID-19 Vaccine
Please indicate the name of the business or institution that is requiring COVID-19 vaccination and whether you are an employee, student or both.
Exemption form?
Yes
No
Has that business or institution provided you with a form to request exemption?
Please briefly describe why you wish to apply for a religious exemption from the vaccine mandate:
Date your exemption is due
Other relevant information
Please add any other information you believe is relevant to your request for religious exemption from the vaccine requirement
How did you hear about us?
I would like to receive email communications from the Independence Law Center / PA Family Institute
Yes
No
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