Registration For Pfizer Vaccination Program - USJ (Booster Dose)
Event Duration:
January of 6th & 7th, 2022 from 9.00AM to 4.00PM
Location:
University of Sri Jayewardenepura, Gangodawila, Nugegoda
To Whom:
Staff and their family members of the university
NIC
*
Name
*
Mobile Number
*
Home Address
*
Department
*
Employee Type
*
Choose Relevant Employee Type
Permanent/Temporary (with Emp. No.)
Contract Basis (without Emp. No.)
Emp Number
*
Preferred Vaccination Date and Time Slot
*
06th of January - 9.00
AM
to 12.00
AM
06th of January - 1.00
PM
to 4.00
PM
07th of January - 9.00
AM
to 12.00
AM
07th of January - 1.00
PM
to 4.00
PM
Any Drug Allergy?
*
Yes
No
I want the vaccine for
*
Only Me
Me and Family
Only Family
Enter the details of family members:
Name
NIC
Relationship
Select
Father
Mother
Spouse
Father-in-law
Mother-in-law
Daughter
Son
Select
Father
Mother
Spouse
Father-in-law
Mother-in-law
Daughter
Son
I/We agree to get the booster dose
Register
Page 1 of 1
