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W. R. Bryan Diabetic Eye Disease Research Fund

<Click Here for Form to Print>

Your Name: ______________________

Date Submitted: _________

Your Phone: _____________

Your e-mail: _____________________

Lion District: _______ (if applicable)

CHECK ONE (If applicable, club may designate recipient):
__________ A Knight for Sight certificate and Bryan pin tab are awarded for a contribution of $100 to the W. R. Bryan Diabetic Eye Disease Research Fund.
__________ A Bryan Fellow plaque and Bryan pin are awarded for a donation of $500 to the W. R. Bryan Diabetic Eye Disease Research Fund.

PLEASE PRINT SO ENGRAVING IS CORRECT ON THE PLAQUE

Donor or Club Name: ________________________________

Recipient: _________________________________

In honor of_______________ ;or, In memory of _____________.

Address – Street (1): _____________________________________

Address – Street (2): ______________________________________

City: ______________________ State:________ Zip:___________

Contributions to the Ohio Lions Eye Research Foundation are tax deductible under section 501 C 3 of the Internal Revenue Code. Send form and check to your district OLERF Trustee or mail to:

Norbert A. Peiker, FAIA, BDB

Executive Director

127 Yorkshire Road

Bellville, OH 44813-1166

Please use separate forms for each award. Thank You