Religious Exemption For Covid Vaccine Form
Employee Name
First Name
Last Name
Please explain why you are requesting an Exemption:
If requested, can you provide documentation to support your belief(s) and need foran accommodation?
Yes
No
Please explain why:
I, undersigned, agree with the following statements:
I verify that the information I am submitting here is complete and accurate to the best of my knowledge.
I understand that any intentional misrepresentation contained in this request may result in disciplinary action.
I understand that my request for an accommodation may not be granted if it is not reasonable, if it poses a direct threat to the health and/or safety of others in the workplace and/or to me, or if it creates an undue hardship on the Company.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: