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Get MI Request for Immunization Record 2016-2024

Name Day Maiden Name Year /  Male  Female Gender: REQUESTOR’S INFORMATION (PERSON REQUESTING RECORD) All requests MUST be accompanied with a photocopy of the requestor’s current state-issued driver’s license or picture I.D. or it will not be processed.  If the record requested is for a person under 18 years of age, please state your relationship to the child.  If the record requested is for a person 18 years of age or older, only the person named on the Immunization reco.

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