CONFIDENTIAL—NATIONAL SECURITY INFORMATION

COVID-19 EMPLOYEE
RELIGIOUS AND MEDICAL EXEMPTION DECLARATION
(REQUEST FOR EXEMPTION)

Employer:_________________________________________________________

________________________________ _______________________________
Employee Name ID No.

________________________________
Department/Location

DECLARATION:

1. I assert that I have sincerely held religious and medical

beliefs and convictions that prevents me from wearing
“non-medical” face masks and face coverings, and from
receiving any of the COVID-19 vaccines and booster shots
that are publicly known to the employer to be capable of
causing the death of a human; has caused the deaths of
thousands of humans of various ages; or has inflicted
serious bodily harm on thousands of humans as reported in
the Vaccine Adverse Event Reporting System (“VAERS”).

I declare under penalty of perjury under the laws of the State of __________

that the foregoing is true and correct.

Date: _________________________ _________________________________

Signature
Place: ________________________

EMPLOYER PLEASE COMPLETE THIS SECTION

____Approved ____Denied Date:________________________

Officer/Agent: __________________________Title:______________________

CONFIDENTIAL—NATIONAL SECURITY INFORMATION