Application

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Eye-Link North Dakota Assistive Equipment Grant Application

The Eye-Link North Dakota Board of Directors reviews and makes decisions on grant applications on an as received basis. Their decisions are final. Applicants will be notified of their application status promptly following the Board decision. Grants may include either new or refurbished adaptive equipment. The Eye-Link North Dakota Board reserves the right to deny funding of a grant for any reason. Assistive equipment grant Applications are available to be printed or filled out on-line by visiting the Eye-Link website at: nd.eye-link.org

Please mail your application to:

Eye-Link North Dakota
Attn: Abby Husar
PO Box 7535, Fargo, ND 58106

* Indicates required field

Full Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Mobile or Work Phone *

Email address (if available) *

Currently a student? *

Yes No

If yes, what type of school or training? *

Are you currently a client of any state agency like ND Assistive or low vision rehabilitation facility? *

Yes No

If yes, name of facility, counselor and phone number *

If no, have you been a client of any rehab facility in the past? *

Yes No

If yes, approximately when was your case closed or your training completed? *

If you are an active client of any training agency, please answer the following:

How was your need for the equipment/training you are requesting determined? *

If your equipment request was denied by any agency or non-profit organization, what reason were you given? *

What type, model or description of adaptive technology and/or training are you requesting from Eye-Link North Dakota? *

Have you ever been a member of the Armed Forces or Reserves? *

Yes No

If yes, what branch? *

The following is optional but would assist Eye-Link North Dakota in providing you a prompt response.

I give Eye-Link, North Dakota representatives permission to contact any former counselors on questions related to the specific equipment that I am requesting to have Eye-Link purchase for me.

Signature *

Date *

For more information visit nd.eye-link.org or call (701) 371-0607

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Eye-Link North Dakota Assistive Equipment Grant Application

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BOARD OF DIRECTORS