Demographic Information (MUST COMPLETE FIELDS WITH A*)
Financial Information (MUST COMPLETE FIELDS WITH A *)
The completion of this application is not a guarantee for funding. Applications are approved on a case-by-case basis and subject to program availability. I understanding that I am applying for subsidized hearing aids through a donor funded program or grant available at JSHC for either myself or a person under my care. I understand that intentionally falsifying information is grounds for termination of services, repossession of devices and dismissal from the practice. By signing below I confirm that the information provided above is true and accurate.
1010 N. Davis Street, Suite 101, Jacksonville, FL 32209
tel: 904.355.3403 fax: 904.355.4143