North Dallas Shared Ministries

Application for Visual Assistance

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First Name * Middle Name   Last Name *

Address *   Apt#   City *   Zip *

Use dashes (-) for Phone #
Telephone where you can be called: *  Official Photo ID number *     Marital Status: *

Use dashes (-) for Date
Sex (M/F): *     Date of Birth (Month/Day/Year): *    Ethnicity*

Apt/Condo/Motel name * Phone: * Landlord:

Move-in Date: *

Additional Adults Age 18 or Over Living in Your Household that need Vision Screening:

Use dashes (-) for SS # and Date of Birth

Name First/Last                                 Sex M/F           Date of Birth     Relationship to you       Social Security #Use dashes (-) 123-45-6789

Children Under Age 18 Living In Your Household that need Vision Screening

Name First/Last                               Sex M/F             Date of Birth     Relationship to you       Social Security #Use dashes (-) 123-45-6789
     
     
     
     
     
     
     



Email Address:  *

Enter Email Address Again:  *

Why do you need vision help?  *