OLERF Research Fellowship fund

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Your Name: _________________________ Date: _____________

District: _____ Your Phone: ________________

Your e-mail: _____________________________

Address: ________________________City: ______________

Zip: _______

CHECK ONE:

__________ RESEARCH FELLOWSHIP SUPPORTER

Any amount is greatly appreciated.

__________ RESEARCH FELLOWSHIP ENDOWMENT

To ensure continued research fellowship support.

__________ SUMMER RESEARCH FELLOWSHIP - $3,000

(under development)

The "Name of sponsor" Summer Research fellowship

(3months)

__________ RESEARCH FELLOWSHIP SPONSOR- $12,000

(under development)

The "Name of sponsor" Research fellowship (1 year)

Notes or further information:_______________________________________________

_________________________________________________________

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:

Norbert A. Peiker, FAIA, BDB

Executive Director

127 Yorkshire Road

Bellville, OH 44813-1166