Eye Contact – November 2016

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
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
- I have undertaken to research the best option for my current circumstances. It is my opinion, in conjunction with opinion of other professional sources as required, that this equipment is: 1. appropriate to my current needs, 2. will be of benefit in assisting me to gain or maintain independence, 3. I have or will gain proficiency in its use and am able to access training if needed.
My contribution for the purchase of the equipment $*
Subsidy amount applied of $*
Signed*
Date*
Date Format: MM slash DD slash YYYY
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
Approved by Manager
Name
First Last
Date
Date Format: MM slash DD slash YYYY