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Los Angeles County Department of Public Health - los angeles county clerk records online
[Insert employer letterhead here]Date: Click or tap to enter a date.I NAME OF STAFF COMPLETING FORM attest that NAME OF EMPLOYEE is:Employed as a NAME OF OCCUPATION and works in one of the Food and Agriculture, Early Childhood Education and Childcare, or Emergency Response categories that are eligible to receive COVID-19 vaccination, and Working in person at a worksite, andEmployed by NAME OF BUSINESS located at: ADDRESS OF BUSINESS.Job Title of Staff completing Form: ______________________________Signature of staff completing form: ____________________________ LAC DPH 3/1/21 Employer (computer)
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