Eye Mobile Request Form
                                  Please fill form completely and accurately as possible.

                   Screening Parade Health Fair Other

                        Time Requested: From:     Until:
                        Request Date:      # Days Requested:
                        Lions Club:      Club President:
                        Contact Person:       Email:
                        Phone: 

                        Where is Eye Mobile to be located?                   Directions to event:
                                       

                       Driver:  Sponsoring club is responsible to obtain qualified driver from link.
                       Payment: Checks payable to: District 33N Eye Mobile Inc. must be attached to form.
                       Do your volunteers know how to use equipment aboard Eye Mobile?
                       Driver training is available through the Eye Mobile Committee.
                       If Eye Mobile is not returned clean a $50.00 cleaning fee will be billed to your club.

                       Upon receiving completed form a confirmation number will be issued to you.

                                  Please print copy of this form and send along with check ($50.00) to:
                                                                 Louise Wojtkiewicz
                                                                     11 Lillian Rd
                                                                      Acton, MA
                                                                         01720
               

                                                               

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