Please complete ALL of the information listed below.
Each individual needs to complete their own separate request.
NOTE: Order 28(1) of the COVID-19 prevention orders (signed December 27, 2021) issued under the authority of
The Public Health Act states that a person must not copy, modify or alter, or (without authority) create a
document or other item that provides, or purports to provide, proof of a person’s vaccination status. It is an offence
under clause 90(1)(b) of The Public Health Act for a person to fail to comply with an order made under this Act. A person who is guilty of this offence is liable on summary conviction to a fine of not more than $100,000 or imprisonment for a term of not more than one year, or both.