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W. R. Bryan Diabetic Eye Disease Research Fund
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: OLERF, 3375 Hoover Road, Grove City, Ohio
43123. Please use separate forms for each award. Thank You
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W. R. Bryan Diabetic Eye Disease Research Fund
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