You must live in a zip code in Dallas County! Eyeglass Applicant InformationName(Required) First Middle Name Last Name Street Address - Do Not Type City, State or zip code in here.(Required) Apt # City - Do not type anything other than the name of the city you live in.(Required) Zip Code(Required) Telephone Number where you can be called(Required) Type of phone:(Required)Select OneCellHomeSocial Security # Official Photo ID #(Required) Sex (M/F):(Required)Select OneMaleFemaleDate of Birth(Required) MM slash DD slash YYYY AgeMonth(s)Ethnicity:(Required)Select OneWhiteBi-RacialBlackHispanicAsianOtherMarital Status:(Required)SelectSingleLiving TogetherMarriedDivorcedWidowedOtherEmail Address:(Required) Enter Email Address Again:(Required) Household InformationWhere do you live:(Required)SelectApartmentCondoHouseDuplexMotelShelterTrailerOtherApt/Condo/Motel name:(Required) Apt Number Hiddentoday Date MM slash DD slash YYYY Move-in Date(Required) MM slash DD slash YYYY Time Lived at Residence:Year(s)(Required)YOU MUST FILL IN THIS FIELDMonth(s)Landlord Name:(Required) Phone:(Required) EYEGLASS ASSISTANCE NEEDEDBrief explanation of why you need this help?(Required)YOU MAY BE REQUIRED TO MAKE 2-3 VISITS TO NDSM. 1 - FOR PRE-SCREENING TO SEE IF YOU NEED A PRESCRIPTION AND/OR READERS. 2 - FOR ACTUAL VISIT TO GET PRESCRIPTION IF NEEDED. 3-TO PICK UP YOUR EYEGLASSES WITH PRESCRIPTION.A RESPONSE WILL BE EMAILED TO YOU WITHIN 2-4 DAYS ONCE YOU SUBMIT.PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS.EmailThis field is for validation purposes and should be left unchanged. By submitting your mobile number, you agree to receive text messages from NDSM. You can opt-out anytime. Message and data rates may apply. Updated 8.8.2023.
