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2. Please complete this form if you are interested in an on-site COVID-19 vaccination clinic through Walworth County Public Health. We will follow-up within 48-72 to discuss your request.

4. Organization/Employer Name*
6. Address*
8. Contact Person*
10. Contact Person Email Address*
12. Contact Person Phone Number*
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13. 1. Receive an email copy of this form.
14. Email address

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15. Submit

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