OLERF APPLICATION FOR RESEARCH AWARD -

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Your Name:____________________District: __  Date Submitted: _____________ 

Your Phone: ___________________   Your e-mail: ________________________

CHECK ONE:

__________  RESEARCH SUPPORTER – up to $499.00

• Certificate of appreciation awarded to the club

__________  LEADERSHIP AWARD - $500.00 TO $999.00

• Bronze pin for president (or club’s designee) and banner patch

__________  VISIONARY AWARD $1,000.00   TO $2,499.00

• Silver pin and silver plaque for president (or club’s designee)

____________   FOUNDER’S AWARD - $2,500.00  and up.

• Gold filled pin and gold plaque for president (or club’s designee)

PLEASE PRINT SO ENGRAVING IS CORRECT ON THE PLAQUE

Club/donor________________________________

Recipient _________________________________

In honor of__________________ In memory of____________________

Address – Street___________________________________

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 mailed to: OLERF, 3375 Hoover Road, Grove City, Ohio 43123.  Please use separate forms for each award.