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

                   Screening Parade Health Fair Other

                        Time Requested: From: Select 12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM     Until: Select 12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM 11PM
                        Request Date:      # Days Requested:
                        Lions Club:      Club President:
                        Contact Person:       Email:
                        Phone: 

                        Where is Eye Mobile to be located?                   Directions to event:
                                      MapQuest, Google Maps linking ok!  

                       Driver: Select Below Joe Gentlemen Omer Guillemettee Ray Marchand Bryan Murphy Frank Rossetti Russ Smith John Baker Tim Bell Steve Bourdon Butch Crosbie Mark Alexander Dave Gath Peter McDonald Joan Purdy Mike Sandberg Ken Cuhna Kevin Erb Richard Vargas-Vila  Sponsoring club is responsible to obtain qualified driver from link.
                       Payment: Check Cash Money Order Checks payable to: District 33N Eye Mobile Inc. must be attached to form.
                       Do your volunteers know how to use equipment aboard Eye Mobile? Yes No
                       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