Application Thank you for your interest in Operation Restore Oral Health. Please fill out the application below. Name(Required) First Last Gender(Required)MaleFemaleDate of Birth(Required) MM slash DD slash YYYY Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneMarital Status(Required)SingleMarriedDivorcedWidowedSeparatedHow did you hear about the OROH program?Briefly describe your dental problems(Required)# of Upper Teeth(Required)# Lower Teeth(Required)Name of last dentist & Phone: Approximate date of last dental visit? MM slash DD slash YYYY Please list other cities or how far you are willing to travel in order to get dental treatment:(Required)Number of people in your household:Name of first person: First Last Age of first person:Relationship to you: Monthly Income:Name of second person: First Last Age of second person:Relationship to you: Monthly Income:Name of third person: First Last Age of third person:Relationship to you: Monthly Income:Name of fourth person: First Last Age of fourth person:Relationship to you: Monthly Income:Your monthly household income:(Required)Are you able to work?(Required)YesNoIf no, please explain why:If you are employed, place of employment: Your monthly employment income:(Required)Is your spouse/significant other employed?(Required)YesNoIf no, please explain why:If they are employed, Place of employment: Spouse's/significant other’s monthly employment income:(Required)Monthly amount:Year benefit began: Monthly amount:Year benefit began: Monthly amount:Year benefit began: Monthly amount:Year benefit began: Monthly amount:Year benefit began: Monthly amount:Year benefit began: If you are not receiving disability, have you ever applied?(Required)YesNoTotal value of savings:(Required)Pension:(Required)Type of investments/assets:(Required) Total value of investments/assets:(Required)Do you receive Food Stamps?(Required)YesNoMonthly amount:Do you receive Medicaid benefits?(Required)YesNoMedicaid #: Do you have a Medicare Advantage Plan?(Required)YesNoDo you have dental insurance?(Required)YesNoHousing:(Required)Housing:(Required) Own Rent Food (not including Food Stamps):(Required)Utilities:(Required)Phone:(Required)Cable/Internet:(Required)Credit card/Loan payments:(Required)Medications/Medical Costs:(Required)Out of pocket health insurance:(Required)Life/Burial insurance:(Required)Is there a car in the household?(Required)YesNoMake: Model: Year: Car payment:Car insurance/Car expenses/Gas:Other Monthly Expenses:Total Monthly Household Expenses:(Required)Are any family members able to contribute tocosts of your dental treatment?(Required)YesNoIf yes, please explain:Are any other sources available to help pay for dental care (i.e. churches, service organizations, other agencies, etc.)?(Required)YesNoIf yes, please explain:Use this space to elaborate on any information not sufficiently explained in other areas:
