- Mail completed form to: Grand Lodge of California,
- 122 Race Street, San Jose CA 95126-3040
- Phone 408-867-0231 FAX 408-867-6272
- or Email form to: marlang@msn.com
- Visual Research Director: Mary Lou Lang
- 11220 Monterey CT, Cupertino, CA 95014
- Retain a copy of this form for your files.
To: The Officers of the California Visual Research Foundation, Inc., of the Independent Order of Odd Fellows:
Dear Brothers and Sisters, (Please Print)
I, (name)_______________________________________________, a member of
________________________________________________Lodge No._____________
in (city)_________________________ California,
am in need of the following assistance relating to vision, which exceeds my current financial resources:
____ Financial aid in order for me to see an ophthalmologist.
____ I do not have Medicare or other Insurance.
____ I cannot afford the co-pay for Medicare or my Insurance.
____ A referral from my ophthalmologist to the Wilmer Eye Institute. Please provide a Referral Form. My Lodge will send it and a letter confirming my status to my Ophthalmologist.
(name)____________________________________________________________
(address)________________________________________________________
(city)_______________________(state)_____________
____ Financial aid for a vision test and/or the purchase of eye glasses.
____ An Apple iPad: A portable Tablet that enlarges & that has a stand to use on a desk.
____ A lighted magnifying lens (a Big Eye Lamp) to aid me in reading or doing close work.
_____ Other: _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signed: _____________________________________________________________________
Phone: ___Home___Cell ( _________ ) _________________________________________
Email:_______________________________________________________________________
Mailing Address: ___________________________________________________________
City:_________________________________________________ST__________ZIP________
**Attested: This request was reviewed by an appropriate committee of our lodge and approved by vote of the Lodge on:
DATE: ________________________________________
(Lodge Seal) ___________________________________________, Noble Grand
(**attested) ____________________________________________, Secretary
_______________________________________________________Lodge No. ____________