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Registry Access Application

Accessing the Immunization Registry

This form must be completed by every organization wishing to have electronic access to the Registry. Upon receipt of your request for access, the Registry staff will review your qualifications. If approved, you will be assigned a password. You will receive notification from us within 10 working days.
 Facility Name  
 VFC Number  
 Facility Type  

 Street  
 City  
 State  
 Zip  
 Phone number  
 Fax number  
 Contact name  
 E-mail address  
 


 
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