APPLICATION

LIONS HEARING

RESEARCH FELLOWSHIP

DONOR

Name __________________________________________________________________

Address ________________________________________________________________

City ________________________________________ State _________ Zip _________

Club Name _____________________________________________________________

RECIPIENT

Name __________________________________________________________________

Address ________________________________________________________________

City ________________________________________ State _________ Zip _________

Please Check

___ Individual Fellowship – Gift made by an individual, Lions Club, or Lions District,

to honor someone as a Lions Hearing Research Fellow

___ Memorial Fellowship – Gifts given in memory of a deceased Lion or non-member

___ Cumulative Fellowship – Gifts of $1000.00 or more made over several years (5 year

maximum) with the award Made on receipt of the full amount

___ Progressive Fellowship – Gifts to honor an individual more than once.

AMOUNT OF DONATION $_________________________________

($1000.00 per award)

Please make your check payable to : Lions MD5M Hearing Foundation

Mail check and completed form to:

PDG Floyd Roden

8337 La Beaux Ave NE

Monticello, MN 55362

Mail Award to:

_________________________________

_________________________________

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