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 including SNAP:
_______________________________ ________________________________
Proof of Income and SNAP Benefits are required to be considered
Please list all household expenses on a separate sheet of paper
Circle if the applicant has any of the following: Medical Insurance/Medicaid/Other
Is applicant able to work? Yes No If no, please give reason and is it a (please circle one) temporary/permanent condition? _______________________________________________
Has the Clarksville-Queen City Lions Club helped the applicant with glasses before?____________
If so, please list dates:_____________________________
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
Please call Lion Ed Lantz 407-376-3188 or email edlantz2001@yahoo.com with questions
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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):______________________ Referred to:__________________
Sight Chairperson Signature:_________________________________ Date:_____________
