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Get Lions Affordable Hearing Aid Project Application Form For Candidates 2011-2024

Any/all Health Insurance Policies List Names and Ages of Everyone in Your Household: Name Do you wear a hearing aid? Age Yes No Yes No Relationship If Yes, why do you need one? Is the Applicant employed? If No, why? Employer: Applicant Must Read and Sign This Statement: I fully understand these services are limited to individuals unable to pay for or receive hearing aids from other sources of assistance. In consideration of these services, I release and discharge all persons rendering.

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