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Vaccination Exemption Affidavit
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Vaccine Exemption Affidavit
I, ______, of ______, DO SOLEMNLY SWEAR (or AFFIRM) AND DECLARE:
I was born on ______ in ______.
I am a citizen of ______.
I hereby request an exemption from receiving the ______ vaccine, or any related vaccines, boosters or other shots related to ______ and any of its variants.
The ______ vaccine ______.
The purpose of this Affidavit is to request a formal exemption from any mandatory or non-mandatory vaccination requirements, whether by law, health directive, provincial or state mandate, or resulting from an employer’s rules, policies or orders.
I swear this Affidavit in support of my request for a ______ vaccine exemption, and for no unlawful or improper purpose.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
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