| 6501 East Greenway Parkway Suite 103-553 , Scottsdale, Arizona, 85254 | (480) 898-4828

I, decline my T.A.C.T. and OSHA regulated and
recommended Hepatitis vaccine or Tetanus shot offered free of charge from T.A.C.T. for personal and/or religious reasons.

T.A.C.T. management has explained to me why they recommend the shots and what risks I take to my own health by not accepting the vaccines.

T.A.C.T. has made me aware, and I fully understand that I may accept the vaccines at any point, if I change my mind in the future.

As of this date , I decline the no cost, recommended Hepatitis and Tetanus vaccine shots T.A.C.T. has offered to me.

Employee   Date