COMPLETE THIS APPLICATION FORM ONLY IF:

1.Someone in the household is working at least part time;
2.The person seeking care has no public or private insurance that covers eye exams;
3.The person has not had an eye exam in the last 2 years;
4.The household is low-income and unable to pay for eye exams.

This form not to be used for application in Arizona, California, Colorado, Hawaii, Kansas, Kentucky, Minnesota, Montana, North Dakota, Wisconsin and Wyoming.

Vision USA Application Form