BHARATIYA RESERVE BANK NOTE MUDRAN PRIVATE LIMITED - MYSURU

FORM FOR THE VACCINATION AGAINST COVID – 19

For Employees and Family Members above the age of 18 Years
Date : _________________

Name of the Employee Designation Employee Department /Division Age as on 23rd May Total No. of Persons
No. / Section 2021 (In Years and above the age of 15
Months) years in the Family
(including Self)

Name of the Person Sex Age as on 24.05.2021 Relationship with Name of the !st Dose of 2nd Dose of Vaccine
(in Years and Months) Employee Vaccine Taken Vaccine Taken on Taken on / Due on

I hereby Undertake that the above information provided by me is correct as per my knowledge and information.

Signature of the Employee with date