[City of El Paso] Self Disclosure COVID-19 Form

Date of Birth

Phone Number

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postal Code

County

Country

If you are submitting an AT HOME TEST KIT, Please make sure your Full Name, Date Of Birth, and Date Test Was Done is written on the card.

Please attach a copy of your lab report. One file per submission. (PDF or Image)

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