Eye Contact – November 2016

Beyond Blindness

Name*
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I wish to apply for a subsidy for the following item of equipment:
This item will assist me to:
Suppliers name*
Name
Address*
Address City State / Province / Region ZIP / Postal Code
Phone
Email
Enter Email Confirm Email
Professional endorsement*
- I have assessed the needs of the member and recommend that this technology meets BWA subsidy guidelines and I feel is appropriate and that this member has or will gain proficiency in its use and that it will be of benefit to assisting them gain or maintain independence.
Print Name
Position in the Organisation
Member endorsement*
- I have understood the equipment subsidy guidelines and believe this application meets these guidelines. I will be contributing the amount mentioned below and wish to apply for the subsidy
My contribution for the purchase of the equipment
Subsidy amount applied for
Once you submit your form by using the button below you should be presented with a confirmation page. If you are not presented with a confirmation page, there is an error in your form. Errors will be highlighted.
For office use only
Approved by Member Services Officer
Admin Office checked eligibility
Approved by Manager
Date
Date Format: MM slash DD slash YYYY