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Eyeglass Assistance Request
Eyeglass Assistance Request
Code Able
2019-03-29T09:58:04-04:00
Eyeglass Assistance Request
Applicant Information
Applicant Name
*
Enter the name of the person applying for an eye exam and/or eyeglasses
Applicant Date of Birth
*
Applicant Address
*
Applicant Address
Applicant Address
Applicant Address
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Applicant Phone Number
*
Applicant Email
*
Describe the justification and financial need
*
Describe the applicant's inability to pay for an exam and glasses. Does the applicant have a job? Have insurance? Does the insurance cover eye exams? Do they receive medical assistance?
If you are human, leave this field blank.
Next: Income Qualification
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