PRE-APPLICATION CHECKLIST

This checklist must be completed prior to completing the entire Wheelchair Application.  Once this checklist is complete and submitted, a DGF representative will contact you to discuss eligibility and give you further instructions for completing the application.

*Please note all fields are required

Applicant Name:

Name/Relationship of person completing the application

Street Address:

City:


State:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Home Telephone:


Extension:


Email address:

Date of Birth of Applicant:


Gender (Male/Female):
Male Female

Please answer the following questions regarding the applicant:

• Suffer or have suffered from an injury or illness that leaves the applicant permanently confined to a wheelchair.
  Yes   No
  
  
• Has lived with the injury or illness for at least 6 months.
  Yes   No
  
  
• Is a US citizen or permanent resident of the US for at least six months.
  Yes   No
  
  
• Is at least 2 years old.
  Yes   No
  
  
• Able to provide documentation from a licensed physician stating the medical diagnosis and permanency of the applicant’s disability.
  Yes   No
  
  
• Applicant, parent or legal guardian can demonstrate financial need.
  Yes   No
  
  
• If applicant is covered under private insurance, the applicant can provide a letter from insurance company stating the reason(s) for the denial.
  Yes   No   NA
  
  
  Comments or Questions: (not required)