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This document is an application form for a Certified Yellow Fever Uniform Stamp from the New Jersey Department of Health. It collects information from applicants such as their name, address, medical license number, and designated yellow fever vaccination center. Applicants must be a responsible physician to apply for or renew a stamp, which certifies them to administer the yellow fever vaccine. The form distinguishes between new applicants and renewals, and collects additional details on designated facilities and coordinators if administering the vaccine in multiple locations.

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bhuneshwar paswan
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85 views1 page

Imm 49

This document is an application form for a Certified Yellow Fever Uniform Stamp from the New Jersey Department of Health. It collects information from applicants such as their name, address, medical license number, and designated yellow fever vaccination center. Applicants must be a responsible physician to apply for or renew a stamp, which certifies them to administer the yellow fever vaccine. The form distinguishes between new applicants and renewals, and collects additional details on designated facilities and coordinators if administering the vaccine in multiple locations.

Uploaded by

bhuneshwar paswan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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New Jersey Department of Health

VACCINE PREVENTABLE DISEASE PROGRAM APPLICATION FOR


P.O. Box 369 CERTIFIED YELLOW FEVER UNIFORM STAMP
Trenton, NJ 08625-0369
This form is used for a new Certified Yellow Fever Uniform Stamp or to reapply for certification following the three (3) year expiration of current
certification. Please type or print all information.
Type of Application
New Applicant Renewal-No Changes Renewal-With Changes (Attach Change Notification Form)
UNIFORM STAMP HOLDER INFORMATION
Full Name of Responsible Physician (Stamp Holder)

Mailing Address Medical License Number

City State Zip Code Phone

Physical Address Email Address

City State Zip Code

Current Stamp Number for Recertification NJ Immunization Information System (NJIIS) Provider Number

DESIGNATED YELLOW FEVER VACCINATION CENTER


Legal Name of Designated Facility

Mailing Address

City State Zip Code

Phone Fax Email Address

Shipping Address

City State Zip Code

Phone Fax Email Address

DESIGNATED YELLOW FEVER COORDINATOR


Name of Coordinator

Physician Pharmacist New Jersey Professional Board License/Certificate


Nurse Physician Assistant
Position

Mailing Address

City State Zip Code

Phone Fax Email Address

* To designate additional facilities that are under the jurisdiction of the responsible Physician (Uniform Stamp Holder) to administer Yellow
Fever Vaccine, please complete the Designation of Additional Yellow Fever Vaccination Centers form located on the Yellow Fever Program
webpage at: http://nj.gov/health/cd/topics/yfever.shtml.

SIGNATURE OF RESPONSIBLE PHYSICIAN


Signature of Responsible Physician Date

New applicants should reference the Yellow Fever Program Manual to ensure all required forms are submitted. Forms must be ma iled to the
New Jersey Department of Health, Vaccine Preventable Disease Program at the address above, faxed to the Vaccine Preventable Disease
Program, ATTN: Yellow Fever Vaccine Program at 609-826-4866, or emailed to [email protected] .

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