Online Application Online Application MelC - Eye Care Assistance - Applicant Information: 12 Applicant Name* Date* MM slash DD slash YYYY Phone*Address* Street Address City ZIP / Postal Code Email* Gender* Male Female Date of Birth* MM slash DD slash YYYY Social Security Number* Contact Person (If different) Please include name and relation.Contact Person Phone Requesting Assistance For* Income and Insurance InformationMonthly Household Income* *You must provide proof of income. (First two pages of most current income tax return, W2, pay stubs, etc). Please include any unusual or extraordinary expenses or circumstances on a separate sheet. If no income - include a reference letter from community member, such as a Pastor, Counselor, etc.Upload Proof of Income Below* Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 32 MB. Monthly Expenses* Number of Persons Living in Household: Adults:*Number of Persons Living in Household: Children:*Who Referred You? Insurance Provider:* Please provide a copy of your insurance card below.Upload Copy of Insurance Card Below* Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 32 MB. Signature*Release: I, for myself, my heirs, personal representatives, executors, administrators, and assigns, and on behalf of the patient, if the patient is other than myself and I am the responsible party for the patient, waive, release and forever discharge the Lions Sign & Hearing Foundation (including specifically, but not limited to, the Melvin Clack Fund Advisory Committee), the Lions Clubs of Arizona, and each of their respective officers, directors, agents, representatives, successors and all connection with my and/or the patient's acceptance of assistance from the Melvin Clack Fund Advisory Committee or corresponding eye care paid for through such assistance from the Melvin Clack Fund Advisory Committee any information required.Date* MM slash DD slash YYYY
