Avery Eye Clinic The Difference Makers LASIK Vision Correction Nomination Process

Questions marked with an asterisk (*) are mandatory.


	Welcome to the Avery Eye Clinic Difference Makers Nomination Program Every few months, the doctors of Avery Eye Clinic select someone from our community to receive LASIK Vision Correction at no cost. To be considered for this procedure, individuals are nominated by people that have recognized the nominee as someone that really makes a difference in our community. This list of possible nominees includes teachers, firefighters, police officers, first responders of all types, and people in our military. But you may nominate anyone you believe is making a difference in our community. Nominations from Spring, The Woodlands, Conroe, Huntsville, Bryan and College Station, may be submitted and will be reviewed and evaluated. The selection is based on the recommendation of the person nominating them, the contribution they are making to our community and their qualification for LASIK Vision Correction (not all nominees qualify based on their eye examination). Please nominate someone you feel should be considered for this wonderful gift. Please complete the following few questions to complete the process. Thank you,

NOMINATION

Please enter the name and contact information for the person you wish to nominate.


	2. WHY ARE YOU NOMINATING THIS PERSON? Please indicate below the reasons you have nominated this person.

VALIDATION

To validate your nomination, please provide us with your contact information.

* Date of Nomination

	Month	Day	Year	Time
Date

* ANONYMOUS

Do you wish to remain anonymous?

YesNo

Our sincerest appreciation.

Thank you for participating in the Difference Makers Lasik Vision Correction nomination process.

For confidentiality purposes, recipients and their sponsor are notified only when selected.

All nominated candidates remain eligible for 12 months upon receipt of their nomination.

Warm regards, Avery Eye Clinic