Directions:
Enter all information requested below by typing on the computer keyboard in the available spaces. Use the Tab button to move from box to box or use your mouse to point and click. After all of the information is entered, use the Send button at the bottom of the page to submit the form.
First Name
Last Name
Suffix (MD, etc)
Facility Name
Facility Code
Email
Phone
FAX
Where would you like the Reporting Forms mailed?
Street Address
Address Line 2
Borough
NY,
ZIP
How many Reporting Forms would you like?
Quantity
CLICK the button below to send your form via the internet.
--or-- Print and FAX the form to (212) 208-4641
--or-- Print and MAIL the form to:
Citywide Immunization Registry
P.O. Box 90490
Binghamton, NY 13902
--or-- CALL (800) 238-0130
Click here
if you wish to obtain a voter registration form. Government services are not conditioned on being registered to vote. A voter registration form can also be obtained at http://nyc.gov/html/misc/html/register.html, or by calling (212) 868-3692.
