Please complete the following Initial Request Form to provide us with some basic information: First Name * Last Name * Email * Age Phone Address 1 * Address 2 City * State * Select StateAlabama – ALAlaska – AKArizona – AZArkansas – ARCalifornia – CAColorado – COConnecticut – CTDelaware – DEFlorida – FLGeorgia – GAHawaii – HIIdaho – IDIllinois – ILIndiana – INIowa – IAKansas – KSKentucky – KYLouisiana – LAMaine – MEMaryland – MDMassachusetts – MAMichigan – MIMinnesota – MNMississippi – MSMissouri – MOMontana – MTNebraska – NENevada – NVNew Hampshire – NHNew Jersey – NJNew Mexico – NMNew York – NYNorth Carolina – NCNorth Dakota – NDOhio – OHOklahoma – OKOregon – ORPennsylvania – PARhode Island – RISouth Carolina – SCSouth Dakota – SDTennessee – TNTexas – TXUtah – UTVermont – VTVirginia – VAWashington – WAWest Virginia – WVWisconsin – WIWyoming – WY Zip Code * Summary of Request * Are you able to provide necessary documentation certifying OR self-certifying that you are a person with a visual impairment or disability? Yes No Maybe Are you able to provide appropriate documentation in support of your financial need (e.g. Taxes, income, pay stubs etc.)? Yes No Maybe If you have questions, please contact us at CherishLifeMD@gmail.com
