Please note:  this is not a secure form.

Name of Organization:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Organization Web Site Address:
Total Number of Residents Assisted Living:
Nursing Facility:
Percent of Residents Immunized Pneumococcal:
Influenza:
Our organization is affiliated with (check all that apply):	AAHSA AHCA ALFA NCAL
I do hereby certify that the organization named above has met the following requirements for recognition as a Partner in the 100% Immunization Campaign: 80% of residents have been immunized with pneumococcal vaccine 80% of residents have been immunized with influenza vaccine The organization has established an immunization program that encompasses influenza, pneumococcal, and tetanus-diphtheria vaccines.
I want to join the 100% Imunization Campaign Partner Program at the cost of $25.00 to cover expenses associated with the program.
Method of Payment:	Select One Check Visa MasterCard Amex Discover
Name on credit card:
Card number:
Expiration date:
Signature (if faxed)

If your organization would like to join the 100% Immunization Campaign, Contact us.   The 100% Immunization Campaign is coordinated by The American Society of Consultant Pharmacists.