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) 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 Move-in Date:(Required) (date moved on to property) Landlord Name:(Required) Phone:(Required) EYEGLASS ASSISTANCE NEEDEDBrief explanation of why you need this help?(Required)A RESPONSE WILL BE EMAILED TO YOU WITHIN 24 HOURS ONCE YOU SUBMIT.PLEASE READ SCREEN AFTER YOU CLICK SUBMIT FOR IMPORTANT DIRECTIONS. 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.
