EYEGLASS VOUCHER REQUEST

NALC Branch 41 - 2262 Bath Avenue, Brooklyn, NY 11214
branch41@aol.com - Fax: 718-373-5326

Go to General Vision Servives generalvision.com to find a location

Active members are entitled to one free voucher a year and retired members every 2 years


Member's First Name:

Member's Last Name:

Member's Middle Initial(optional):

Last 4 digits of Social Security #:

Members Station

 

Patient's Name:

Please check a box below to show the relationship of the patient to the member

self spouse child



Member's Signature___________________________ Date ____________

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After filling out the above information email, fax or mail this completed form to Brooklyn Letter Carriers Branch 41