Employer Mandate SECTION ACONTACT INFORMATION / GENERAL INFORMATIONWHO HAS A LEGAL CONCERN?* SELF MY CHILD HOW MANY CHILDREN?I AM A CONCERNED (CHECK ALL THAT APPLY) Select All PARENT TEACHER SCIENTIST ADMINISTRATOR HEALTH PRACTITIONER GRANDPARENT OTHER WHAT IS YOUR CONCERN (CHECK ALL THAT APPLY) Select All VACCINE MANDATE MASK MANDATE PCR TEST MANDATE VACCINE INJURY FULL LEGAL NAME* First Middle Last PHONE*EMAIL* ADDRESS* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code COUNTYHAVE YOU SPOKEN WITH OR HIRED A LAWYER BEFORE ON THIS ISSUE?* NO YES SECTION BEMPLOYER MANDATEHAS YOUR EMPLOYMENT BEEN THREATENED?* NO YES IF “YES” HAS THE THREAT BEEN Select All VERBAL IN WRITING EMPLOYER NAME (COMPANY)NAME OF PERSON ENFORCING MANDATE First Last TITLE (SUPERVISOR / MANAGER)ADDRESS OF EMPLOYER Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PHONEEMAIL COUNTYPhoneThis field is for validation purposes and should be left unchanged. Δ