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Get Georgia Gwinnett College Immunization Form

Office, 1000 University Center Lane, Lawrenceville, GA 30043, or fax to: 678-407-5747. Keep a copy of the completed form for your records. STUDENT INFORMATION Social Security Number/Student ID - - Name Last First Middle Address City State Zip Term/Year of application Age at time of application Date of Birth / / IMMUNIZATION INFORMATION (See the reverse of this form for specific immunization requirements) DATE OF POSITIVE LAB/SEROLOGIC EVIDENCE VACCINE DATE MM/DD/YY DATE MM/DD/Y.

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