COVID-19 Vaccine Interest Form

Please provide contact information to receive notification/update on the availability of the COVID-19 vaccine. By providing the following information you are assisting Fresno County in vaccination planning efforts.

*You will receive notification when the COVID-19 vaccine is made available in your applicable tier or when the vaccine is made available to the general public.

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* 1. Please choose your age criteria:

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* 2. Please provide your first and last name:

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* 3. Please provide your email:

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* 4. Please provide your phone number:

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* 5. Please provide your zip code:

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* 6. Please provide your age:

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* 7. Please provide your current occupation or employer (will be verified at the time of registration):

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