Personal Background Question Title * 1. Are you applying for this grant for a prosthetic eye due to UVEAL MELANOMA or CHOROIDAL MELANOMA? IF NOT, do not continue. Yes, I have been diagnosed with UVEAL MELANOMA or CHOROIDAL MELANOMA. Please submit verification of diagnosis. No (If you select this option, you do not qualify) for this grant. The Ocular Melanoma Foundation is only for patients facing uveal or choroidal melanoma. OK Question Title * 2. Contact Information Full name: * Address: * Address 2: City/town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Country: * Email address: * Phone number: OK Question Title * 3. We will contact you by email. Please be sure to check your SPAM folder often for an email from us. Agree Disagree OK Question Title * 4. What is your gender? Female Male OK Question Title * 5. In what year were you born? (enter 4-digit birth year; for example, 1976) OK Question Title * 6. Marital status: Married Divorced Widowed Other OK Question Title * 7. How many dependent children are you parent or guardian for and live in your household (aged 17 or younger only) and are claimed as such on your tax return? None 1 2 3 4 More than 4 OK Question Title * 8. Have you applied to the OMF for any assistance before (TAG or PAP)? Yes No OK NEXT
