VSP Eyes of Hope Gift Certificates Request

Partner Affiliation

How many gift certificates would you like to request?

VSP Eyes of Hope

Full Coverage

Materials Only

Contact Lens Exam Only

/ 50 VSP Eyes of Hope gift certificates available.

Contact Information

First Name

Last Name

Have you previously ordered Sight for Students gift certificates under another name?

Yes No

If so, please provide all names or spelling variations that you have used in the past.

Email Address

Organization Information

Please provide a single mailing address for all gift certificates, even when ordering for multiple schools or locations. This will significantly reduce the time to process your request and mail them to you.

Organization Name

Tax ID Number or Employer Identification Number (EIN)

ORG ID

Affiliation

Certificates cannot be sent to a home address. Use only a valid U.S. school address.

Mailing Street Address

City

State (enter state abbreviation e.g. CA)

Zip Code

Phone Number to be printed on gift certificates

(This is the phone number that certificate recipients will call if they have questions)

Website

Were you referred to request gift certificates due to a declined mobile clinic request?

Yes No

I attest that I am an authorized representative of the organization selected and will abide by the eligibility criteria when distributing VSP Eyes of Hope gift certificates. I understand that abuse of these guidelines will forfeit my involvement with the program.

I Agree to the Above Statement

Submit

Access Code Required

Gift Certificate Request Form