CONSENT FOR VACCINATION

This is to certify that:

1. I have previously filled out and signed the form entitled “For Masterlisting of Eligible
Population for Moderna Vaccination” prepared by the Human Resources departments of
the different companies in the Pryce Group of Companies (Pryce Gases, Inc., Oro
Oxygen Corp., Pryce Corporation, Pryce Pharmaceutical, etc.).

2. I reviewed my answers to said form and said answers are true and correct.

3. I understand the benefits and risks of the vaccine

By signing this form, I give permission for a vaccine to be administered me and a record of the
vaccination to be entered into the registry of the company’s healthcare provider, vaccinator, as
well as all registries of the government for care coordination, vaccination coverage monitoring,
and for all other health and legal purposes.

_______________________
Signature above printed name

Date: