*1.Contact information(Required.)

Name of Individual completing this form *

Company / Organization Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

*2.Business/ Organization website address(Required.)

*3.Number of Employees(Required.)

1-10 Employees

11-49 Employees

50-99 Employees

100-499 Employees

500+ Employees

Other (please specify)

*4.My workplace qualifies for a COVID Stops Here designation as the percentage of our staff fully vaccinated against COVID-19 has reached:(Required.)

100% vaccination against COVID-19 — Platinum

90-99% vaccination against COVID-19 — Gold

80-89% vaccination against COVID-19 — Silver

70-79% vaccination against COVID-19 — Bronze

5.Upload your company logo here

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