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| * (Please scroll over each item for clarification) |
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Donor Information |
| Please make my donation Anonymous |
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Recipient Information
*Recipient Name
(as you would like it to appear on plaque)
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Special Instructions Box
If donations are made on behalf of a member please list the member name(s) and amount(s) in the box above.
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Payment Information
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| /15/ * Ending Date |
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| Recurring credit card payments will be made on the 15th of each month |
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| *Card Type |
Visa
Master Card
American Express
Discover |
| *Name on Card |
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| *Address |
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| *City |
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| *Country |
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| *Postal Code |
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| *Credit Card Number |
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| *Expiration Date |
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| *CVV |
Whats This? |
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© 2011 Lions Clubs International Foundation|300 W 22nd Street, Oak Brook, IL 60523-8842|lcif@lionsclubs.org