APPLICATION FOR W. P. WOODS FELLOWSHIP

The undersigned Lions Club or Lion in good standing does hereby submit the name of

______________________________________________

for a W. P. Woods Fellowship.

The following is a summary of nominee's contribution to the principles of Lionism:

(An additional sheet can be attached if needed)

A check to the Indiana Lions Foundation for Five Hundred ($500.00) Dollars is enclosed. Indiana Lions Foundation is qualified under 501(c)(3) of the Internal Revenue Service Code as a public charitable trust.

The following information on the proposed recipient is for your permanent records:

Applicant (Individual or Organization)

I

Name * Authorized Officer (of a Lions Club)

Street Address, City, State Zip Code Telephone Number

Name of nominee:

Spouse's Name Typed or printed name of signer

Street Address  

City, State

Zip Code

Installment payments of not less than $125.00 may be made on W. P. Woods Fellowships:

*Installment (dollar amount)

For installment payments the name of the nominee may be left blank.