Vaccine Voucher Application (COVID-19)

Year Month Day

年 月 日

The Mayor of Toyohashi

Furigana
Applicant Name

Address

TEL

Relationship to individual(s) being vaccinated:

□Self □Member of Same Household □Other（ ）

I am applying for a vaccine voucher for the individual(s) listed below

〇Information for Individual(s) to be Vaccinated

Previous City/Country
Furigana of Residence
Address Date of Birth
Full Name Date of Relocation to

Toyohashi

□Same as Applicant □Same as Applicant Year

年
1 Month Day
City/Town
月 日 Year Month Day
年 月 日

□Same as Above Year

□Same as Above
年
2 Month Day
City/Town
月 日 Year Month Day
年 月 日

□Same as Above Year

□Same as Above
年
3 Month Day
City/Town
月 日 Year Month Day
年 月 日

〇Shipping Address
※Only write an address if it is different from the one listed in your certificate of residence (Juuminhyou)

Full Name Address

□Same as Applicant
1

□Same as Above
2

□Same as Above
3

〈Continued on Reverse〉
〇COVID-19 Vaccination History

Vaccination Location
Full Name Vaccination Date Vaccine Type
（City or Country）
Year Month Day
1st 年 月 日
Year Month Day
2nd 年 月 日
1 Year Month Day
Number of Doses (Circle One) 3rd 年 月 日
Year Month Day
4th 年 月 日
０回・１回・２回 Year Month Day
5th 年 月 日
３回・４回・５回・６回
Year Month Day
6th 年 月 日

Vaccination Location
Full Name Vaccination Date Vaccine Type
（City or Country）
Year Month Day
1st 年 月 日
Year Month Day
2nd 年 月 日
2 Year Month Day
Number of Doses (Circle One) 3rd 年 月 日
Year Month Day
4th 年 月 日
０回・１回・２回 Year Month Day
5th 年 月 日
３回・４回・５回・６回
Year Month Day
6th 年 月 日

Vaccination Location
Full Name Vaccination Date Vaccine Type
（City or Country）
Year Month Day
1st 年 月 日
Year Month Day
2nd 年 月 日
3 Year Month Day
Number of Doses (Circle One) 3rd 年 月 日
Year Month Day
4th 年 月 日
０回・１回・２回 Year Month Day
5th 年 月 日
３回・４回・５回・６回
Year Month Day
6th 年 月 日

※Please attach copies of items to verify the individuals’ vaccination history and copies of official forms of
ID.
※If you have unused vaccine vouchers received before your move from your previous city/municipality,
please dispose of them.
※If you have completed the designated interval between vaccinations, a vaccine voucher will be sent to you
within 2 weeks of your application.