Fillable Religious Exemption Certification Form (Virginia Polytechnic Institute and State University)

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Religious Exemption Certification Form (Virginia Polytechnic Institute and State University)

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The Religious Exemption Certification Form (Virginia Polytechnic Institute and State University) form is 1 page long and contains:

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Office for Equity and Accessibility
300 Turner Street NW (0150)
North End Center, Suite 2300
Blacksburg, Virginia 24061
P: 540-231-2010
F: 540-231-3830
oea.vt.edu equityandaccess@vt.edu
Religious Exemption Certification Form
Employee Name: Date of Birth: __________
Employee ID Number:
Presidential Policy Memorandum (PPM) 317 sets forth the University’s vaccination and testing requirements.
The administration of the COVID-19 vaccine conflicts with my sincerely held religious tenets or practices. I
understand and agree that I will abide by the requirements set forth in PPM 317 with the exception of the
vaccination requirement.
Signature Date
Notary Acknowledgement
I hereby affirm that this religious exemption certification form was signed in my presence on:
This day of , 20
in the city/county of , state of
Notary Public Seal Notary Signature
My commission expires:
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Religious Exemption Certification Form (Virginia Polytechnic Institute and State University)

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Completed 15 November 2021

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