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CLARKSVILLE QUEEN CITY LIONS CLUB APPLICATION FOR SERVICES

ADULT APPLICATION

Applicant's Name:_______________________________Date of Birth:____________

Address:_______________________________________Phone:(    )_____________

How long have you lived at this residence?__________________________________

Employer:________________________________     Salary:___________per month

List all other incomes in the household and their amounts per month:

_______________________________           ________________________________

_______________________________           ________________________________

Circle if the applicant has any of the following:  Medical Insurance/Medicaid/Medicare/Other (if so please list):_____________________

Family Expenses Per Month:

Home (circle one)   Own      Rent             Payment Per Month:_____________

Own a car? (circle one)      Yes          No                Payment Per Month:_____________

Car insurance (if you own a car)                             Payment Per Month:_____________

Food                                                                           Total Per Month:________________

Credit Card(s)                                                           Payment Per Month:_____________

Medical Bills                                                              Payment Per Month:_____________

Loans                                                                         Payment Per Month:_____________

Cell Phone? (circle one)    Yes           No               Payment Per Month:_____________

Electric Bill                                                                 Payment Per Month:_____________

Phone Bill                                                                  Payment Per Month:_____________

Cable Bill/Internet Bill/Both                                       Payment Per Month:_____________

Water Bill                                                                    Payment Per Month:_____________

Other Bills                                                                   Payment Per Month:_____________

Is applicant able to work?   Yes       No              If no, please give reason and is it a (please circle one) temporary/permanent condition? ___________________________________________________

_____________________________________________________________________________

Date of last eye exam __________     Please attach a current eyeglass prescription if available.

Glasses are needed for (please circle):     Driving           Reading           All the time

Has the Clarksville-Queen City Lions Club helped the applicant with glasses before?____________

              If so, please list dates:_____________________________

Applicant (or legal guardian), please sign the following statement:

I certify that all the above information is factual and accurate and is a true representation of my economic and employment status to date.

Signature:___________________________________________     Date:_____________________

________________________________________________________________________________

Mail the signed application to:                                Clarksville-Queen City Lions Club

                                                                                       106 West Park Drive

                                                                                       Clarksville, TN 37043

________________________________________________________________________________

For Lions Club use only:   I certify that the above applicant and information has been thoroughly researched by the sight committee and myself.  We recommend this application to be:

                Approved                                      Rejected (reason):__________________________

Sight Chairperson Signature:_________________________________       Date:_____________

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