We've Been Vaccinated

Use this form to affirm that your business or household is in compliance with the Oneida County “We’ve Been Vaccinated” Program. Participating businesses will be listed on the county’s website: www.ocgov.net.

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* I am completing this form for a...

Business

Family

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* Business Name or Household Name (i.e. ACME Inc. or J. Doe Family)

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* Your Name

First Name

Last Name

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* Phone Number (Answer at least ONE)

Cell Phone Number

Landline Phone Number

Business Phone Number

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* Business or Personal Email Address

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* Business or Personal Location Address

Enter the address of your physical place of business or residence in New York State or, if a construction project, the primary address of the construction site.

Address *

Apt/Suite/Office/PO BOX

City/Town *

State/Province *

ZIP/Postal Code *

County *

I am the owner or agent of the business listed or the head of a household. I attest that 100% of our staff or family members eligible for the vaccine have been vaccinated. I understand that it is my responsibility to recertify compliance on a monthly basis.

We've Been Vaccinated

Question Title

* I am completing this form for a...

Question Title

* Business Name or Household Name (i.e. ACME Inc. or J. Doe Family)

Question Title

* Your Name

Question Title

* Phone Number (Answer at least ONE)

Question Title

* Business or Personal Email Address

Question Title

* Business or Personal Location AddressEnter the address of your physical place of business or residence in New York State or, if a construction project, the primary address of the construction site.

* Business or Personal Location Address

Enter the address of your physical place of business or residence in New York State or, if a construction project, the primary address of the construction site.