Claim your Free Vaccine Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Do you have health insurance? *YesNoHow did you hear about us? *What type of Class A semi-truck driver are you? *OTR (away from home 4 or more nights/week)Regional (away from home 4 or more nights/week)Regional (away from home less than 4 nights/week)Local (home nightly, or mostly nightly)Please Upload a Copy of your Class A CDL: * Drag & Drop Files, Choose Files to Upload Please indicate what vaccine(s) you'd like to receive: *FluPneumoniaShinglesCovid-19Please select where you plan on using the voucher: *WalgreensKroger and Kroger Family of PharmaciesThe Little ClinicWalmart/Sam's ClubNOTE: Flu vaccines available from September thru April Question or CommentSubmit