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OLERF APPLICATION FOR RESEARCH AWARD -

<Click Here to Download form to Print (Word)>

Your Name:

 

District:

 

Date Submitted:

 

Your Phone:

 

Your email:

 
               

  

CHECK ONE:

__________ RESEARCH SUPPORTER – up to $499.00

·         Certificate of appreciation awarded to the club

__________ LEADERSHIP AWARD - $500.00 TO $999.00

·         Bronze plaque for club president or club’s designee and lapel pin.

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

·         Silver plaque for club president or club’s designee and lapel pin.

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

·         Gold plaque for club president or club’s designee and a lapel pin.

_____ W. R. Bryan Award for Diabetic Eye Disease Research - $500.00

         _____  Richard "Dick" Neiderhauser Award forResearch into

                    Macular Degeneration and Allied Retinal Diseases - $500.00

         ·       Plaque and lapel pin for club designee.  Click HERE for form.

PLEASE PRINT SO ENGRAVING IS CORRECT ON THE PLAQUE

Club/donor

 

Recipient

 

In honor of

 

In memory of

 

Address – Street

 

City

 

State

 

Zip

 

Special Instructions: 

 

 

 
                   

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.