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Immunization Record Request

Please complete the information listed below to request a copy of your immunization record(s). This is ONLY for immunization records.

*Student Name:

University ID Number:

*Birth Date:

ľ¹ÏÓ°Ôº Email:

*Last Semester Attended ľ¹ÏÓ°Ôº

*Fall     Year:     *Spring     Year:
Please send me a copy of my immunization records via (choose one option below):

 Lewis Email 
 Other Email:  
 Fax Number 
 Mailing Address 
Security Password (Please type the word ):

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