On this _ day of _, _, before me, _, personally appeared, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same as for the purposes therein contained. On this _ day of _, _, before me personally appeared, to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he/she executed same as his/her free act and deed. Subscribed, sworn to and acknowledged before me by, the Employee, this _ day of _. This instrument was acknowledged before me on this _ day of _, _ by. The foregoing instrument was acknowledged before me, by means of ☐ physical presence or ☐ online notarization, this _ day of _, _ by, who is personally known to me or who has produced _ as identification. In testimony whereof, I have hereunto subscribed my name at _, this _ day of _, _. The foregoing instrument was acknowledged before me this _ day of _, _ by, who is personally known to me or who has produced _ as identification.īefore me, a Notary Public (or justice of the peace) in and for said county, personally appeared the above named, _, and _, who acknowledged that they did sign the foregoing instrument, and that the same is their free act and deed. I understand that, my exemption notwithstanding, I may be prohibited from working in person or subject to other accommodations during an epidemic or pandemic. that a person who does not receive the required vaccinations is at risk of spreading these diseases to other persons that a person who does not receive the required vaccinations is at risk of contracting those diseases andĭ. that the required vaccinations are safe Ĭ. that the required vaccinations are necessary to prevent the spread of dangerous diseases among the people of this state ī. I understand that the Department of Public Health has determined:Ī.
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