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?___________ Number in Household______
Employer:________________________________ Salary:___________per month
List all other incomes in the household and their amounts per month:
_______________________________ ________________________________
_______________________________ Food Stamps______________________
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
5087 Minnis RD
Springfield, TN 37172
________________________________________________________________________________
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:_____________
