New Eyes for the Needy Bringing Vision to the US and the World Bringing Vision to the US and the World
Individuals Needing Assistance Optical Dispensers Vision Missions
Our Vision
Providing Glasses in the US
The Need
Our Voucher Program
How the US Program Is Funded
Who Receives the Glasses?
Who Is Eligible?
How to Apply for Assistance
Sources of Free Eye Exams
How the Program Operates
Participating Agencies
Special Programs & Partnerships
Agency Resources
Participating Dispensers
Optical Dispenser Resources
     Memo for Dispensers (PDF)
     Vouchers and Rates (PDF)
     Dispenser Inquiry Form
     Dispenser Request Form
Program Updates
Providing Glasses Overseas
Impact: How You Can Help
People: Partners & Supporters
News
Contact Us
Providing Glasses in the US Optical Dispenser Request Form
Please fill out the form below to:
  		• Request an extension on the expiration date of a voucher
  		• Request approval for reimbursement for additional services

    A representative from New Eyes will contact you to follow up on your request.

    * indicates a required field
    Dispenser Name*
    Contact Person*
    Dispenser # (if known)
    Day Telephone #*
    Email Address*
    Requests: Please extend the expiration date on voucher #

      to the following date:
       Format: MM/DD/YYYY
    Please approve reimbursement for the following additional services:
    We are making this request for the following reasons:





    Helpful Links | Forms | Sitemap | Privacy Policy | Terms and Conditions
    © Copyright 2008-2010 New Eyes for the Needy
    549 Millburn Avenue, Short Hills, NJ 07078 | 973-376-4903
    Designed and Developed by Interactive Media Associates