This government document is issued by The Office Of Lt. Governor Boyd K. Rutherford for use in Maryland
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https://www.google.com/url?client=internal-element-cse&cx=007821330218074952993:xwjvjbmpp6q&q=https://governor.maryland.gov/wp-content/uploads/2021/04/VETF-Vaccination-Request-Form.pdf&sa=U&ved=2ahUKEwjHq6TY3q_xAhXOnIsKHQEgB1wQFjAAegQIAhAB&usg=AOvVaw29RrZ-PThMqaJlMH_-CXmk