Lions Clubs International Foundation

Title/Salutation	Select Dr. Miss Mr. Mrs. Ms.
*Member Name
*Member ID
*Club Name
*Club Number
*Member Address Line 1
Member Address Line 2
Member Address Line 3
*Member City
Member State/Province
*Member Country
Member Postal Code
*Member Phone
*Member Email

*Club Name
*Club Number
Officer Title	N/A President Vice President Treasurer Secretary
*Club Address Line 1
Club Address Line 2
Club Address Line 3
*Club City
Club State/Province
*Club Country
Club Postal Code
*Member Phone
*Member Email

*Contact ID
*Contact Name
*Address Line 1
Address Line 2
Address Line 3
*City
State/Province
*Country
Postal Code
*Phone
*Email

*Contact ID
*Contact Name
*Address Line 1
Address Line 2
Address Line 3
*City
State/Province
*Country
Postal Code
*Phone
*Email

Title/Salutation	Select Dr. Miss Mr. Mrs. Ms.
*Name
*Address Line 1
Address Line 2
Address Line 3
*City
State/Province
*Country
Postal Code
*Phone
*Email

Recipient Information
*Recipient Name
(as you would like it to appear on plaque)

Shipping Information for Recognition
*Name
*Address Line 1
Address Line 2
Address Line 3
*City
State/Province
*Country
Postal Code
*Phone
Email

For contributing member donations being submitted by clubs, please specify name(s) and amount(s) of members receiving a pin.

Payment Information

*   Monthly

Quarterly

Semi Annual

Annual

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