Home Address

City State Postal Code

Home Phone Cell or Work Phone

Email Address (If Available)

Current Student? Yes No - If yes, type of school or training?

Are you currently a client of State Services for the Blind? (SSB) Yes No

If yes, name of Counselor Phone

If no, have you been a client in the past? Yes No
If yes, approximately when was your case closed?

If you are an active client of SSB please answer the following:

How was your need for this equipment/training determined?

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

If you were denied by SSB, what reason were you given for being denied?

NOTE: You must attach a copy of your letter of denial from SSB or Counselor to this application! Your application will NOT be processed if a letter of denial is not attached!
The following is optional but would assist Eye-Link in making a prompt response:

I give Eye-Link representatives permission to contact my SSB Counselor on questions related to the specific equipment I am requesting Eye-Link to purchase for me.

Signature _________________________________________ Date ________________________

Mail your application to:
The Eye-Link Foundation - M.E. Appelgate
5253 27th Avenue South
Minneapolis, Minnesota 55417