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Please fill out your first and last name.
What is your date of birth?
Please provide a phone number in case we need to contact you.
Please select the option that best suits why you're requesting a letter.
Please list your place of employment.
Please give the name of the person with COVID-19 you were exposed to, unless you are the positive case then put "N/A" in each field.
If you are a close contact, please select the last date you were in contact with the COVID-19 positive person. If you have tested positive, please select the date you became symptomatic or the date you were tested if you were tested without symptoms.
Please select if you would like this e-mailed, or mailed to your place of residence.
Please include the email address you would like your letter to be sent to.
Please fill out your address below if you would like the letter mailed to your residence.
This field is not part of the form submission.
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