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Revision January 2013 - Page 1 of 2 University of North Georgia Certificate of Immunization STUDENT INFORMATION Name Last First Middle Social Security Number/Student ID Date of Birth Age at time you will begin classes at North Georgia Term of Application please circle Fall / Spring Summer of 2 REQUIRED IMMUNIZATION INFORMATION VACCINE DATE MM/DD/YYYY DATE OF POSITIVE LAB/SEROLOGIC EVIDENCE HISTORY MMR 1 Measles 1 Mumps 1 Rubella 1 Tetanus-Diphtheria Pertussis Whooping Cough 4 Hepatitis B 2...
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