Application Forms

All application forms are available for download in PDF format. Please see our Guidelines and Frequently Asked Questions for more details about these forms.

To view PDF files, you must have Adobe Reader installed on your computer.

Long Application Form

This form may be used to apply for funding up to $1600 (with a maximum of $800 per hearing aid).

English Long Form

Spanish Long Form

Short Application Form

This form may be used to apply for funding in amounts of $300 or less.

English Short Form

Spanish Short Form