WHEELING LIONS CLUB

APPLICATION FOR HEARING AID

Name of Applicant______________________________________Spouse____________

Address of Applicant______________________________________________________

If PO Box, where do you live?________________________Telephone______________

Number of Dependents_______Applicant’s Age_______

Parent or Guardian_________________________________Telephone______________

Own or Buying Home______Renting______Monthly Mortage/Rent Payment_________

Mortgage Holder or Landlord_______________________________________________

Monthly Income__________Source__________________________________________

Employer Name/Address___________________________________________________

If employable, would you accept a minimum wage job?_____

Are you seeking employment?_____________

If not employed, last day of work___________Reason for leaving__________________

_______________________________________________________________________

Disablities that prevent employment__________________________________________

_______________________________________________________________________

Family Doctor/Address/Telephone___________________________________________

Have you had a hearing test recently?_______By whom?_________________________

Diagnosis?______________________________________________________________

Do you now wear a hearing aid?___________From what local hearing aid firm?______ _______________________________________________________________________

Comments ______________________________________________________________

_______________________________________________________________________

Signature of Applicant_____________________________________Date____________

*Applicants must provide a telephone number for contact.

Mail application to: Wheeling Lions Club

P.O. Box 1122

Wheeling, WV 26003

You will be informed of the decision on the application.

For Lions Club use

Name_______________________________Address_____________________________

Service______________________________Provider_____________________________

Approximate Cost_________Approved_________Club Expense__________

Referred to Foundation________

Denied________Comments________________________________________________________________________________________________________________________

For the Committee________________________________________________________