LIONS OF VIRGINIA Multiple District 24

APPLICATION

THE VIRGINIA DISTINGUISHED HUMANITARIAN AWARD

The following persons has been nominated to receive the above award. Our club/my personal check of $750 is enclosed or partial payment of ______ is enclosed. Memorial donation ___ yes or no___

(May be made in one, two or three payments over up to three years)

1st payment Check# _________ Check Date __________ Amount $ ________________

2nd payment Check # ________ Check Date __________ Amount $ ________________

3rd payment Check # ________ Check Date __________ Amount $ ________________

Name of Recipient  ( as it is to appear on the plaque) Please print or type

Mr/Mrs/Lion/Lioness/Honorable)____________________________________________

Address of Recipient _____________________________________________

______________________________________________________________

Telephone Number ______________ Fax Number ________E-Mail_________________________

Name of Sponsoring Club__________________________________________________________

District _________ Date of Application________________________________________________

Name/ Address of Club Secretary____________________________________________________

______________________________________________________________________________

______________________________________________________Zip + 4__________________

Signature _________________________________________________Club Secretary or President

Telephone Number________________ Fax Number ___________ E-Mail ____________________

Date by which Award must be received ________________________________________________

(please allow 30 days for processing)

NOTE: The plaque will be sent to the Club Secretary after total of $750.00 is received, unless otherwise indicated above.

Please mail application and check to your District Representative