Lions Eye Bank
of Manitoba and Northwest Ontario Inc.
320 Sherbrook Street
Winnipeg, Manitoba R3B 2W6
(204) 772-1899 1-800-552-6820 Fax: (204) 943-6823
Request for Prescription Eyeglasses and Eye Exam
When applying for Eyeglasses, a Revenue Canada Statement of Assessment for both recipient and spouse (or legal guardian if child) should be included with this application.
Referral: ______
Referral Contact: ______Ph.:______
Applicant Name:______Date of Birth:______/_____/____
yyyy mm dd
Address: ______
Mailing address: ______Postal Code: ______
(If different)
Telephone Home: ______Work: ______Cell: ______
Email address: ______
Eye exam required: (Y/N) ______
Reasons for requesting assistance: ______
______
______
______
______
Have you requested assistance from another organization? (Y/N)______
Lions Eye Bank
of Manitoba and Northwest Ontario Inc.
320 Sherbrook Street
Winnipeg, Manitoba R3B 2W6
(204) 772-1899 1-800-552-6820 Fax: (204) 943-6823
Request for Eyeglasses (part 2)
Provincial Health #: ______Group Insurance Carrier: ______Plan #:______
Employer: ______Unable to work? ______
Supervisor: ______Contact phone :______
Monthly Expenses: Monthly Income:
Food: $______Take home pay: $______
Rent/Mortgage $______Family Allowance $______
Utilities: $______Workers Compensation: $______
Vehicle: $______Employment Insurance: $______
Other: $______Other Income: $______
Total Expenses: $______Total Income: $______
Family Assets: ______
______
______
(Example: RRSP’s, Mutual Funds, Term Deposits, Bonds etc.)
# Of children in family: ______Ages: ______
# Of dependants (other than children): ______
Other important information: ______
______
______
______
I verify that the information provided is complete and correct to the best of my knowledge.
______
Signature of Applicant Signature of Referral
All information provided will be kept strictly confidential.