Current Page 1 Page 2 Preview Identification Provide contact details for the practice, clinic, long term care or community care facility below. Business/Organization Name Contact First Name Contact Last Name Address 1 Address 2 City, Town, or Community Province Postal Code Example: C1B 0X1 or 12345 Country Telephone 1 For example: 902-555-5555 Telephone 2 For example: 902-555-5555 Fax Number For example: 902-555-5555 Email Address Are you the immunizer or the person ultimately responsible for the vaccines as per the Influenza Immunization Policy? - Select -YesNo Additional Contact Information Provide contact details for the immunizer or person responsible for the vaccines below. First Name Last Name Telephone For example 902-555-5555 Email Address