Request Electronic Proof of COVID-19 Vaccination

Please complete and submit the following information to receive your secure Proof of Vaccine Credential from the Government of Northwest Territories.

Identity Confirmation

To obtain your proof of vaccination in electronic format (PDF with QR code):

Does the applicant have a legally registered single name? *

Single name

Family name

First name

Date of birth *

Month *

Day *

Year *

NWT Health Care Card

Out of territory Health Care Card

NWT Health Care Card Number

Valid if you provided an NWT Health Care Card number at the time of your vaccination in the NWT.

Health Care Card Number

Valid if you provided an out of territory health care card number at the time of your vaccination in the NWT.

Date of your first COVID-19 vaccination *

Month *

Year *

Commercial name of your first COVID-19 vaccine *

Terms and Conditions

I certify that the information entered on this form is complete, current, and accurate. I also agree that my information will be shared with the NWT Health and Social Services Authorities, which will provide me with my digital proof of vaccination.

I have read and accept the form terms and conditions as well as the Terms of Use.

Attention
The proof of vaccination and QR code contain personal information that cannot be used without consent. You may not download another person’s proof of vaccination and QR code without their consent.

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Request Electronic Proof of COVID-19 Vaccination

Identity Confirmation

Terms and Conditions