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Personal Background
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.
*
2.
Contact Information
(Required.)
Full name:
*
Address:
*
Address 2:
City/town:
*
State:
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
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Country:
*
Email address:
*
Phone number:
*
3.
We will contact you by email. Please be sure to check your SPAM folder often for an email from us.
(Required.)
Agree
Disagree
*
4.
What is your gender?
(Required.)
Female
Male
*
5.
In what year were you born? (enter 4-digit birth year; for example, 1976)
(Required.)
*
6.
Marital status:
(Required.)
Married
Divorced
Widowed
Other
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
*
8.
Have you applied to the OMF for any assistance before (TAG or PAP)?
(Required.)
Yes
No
Current Progress,
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