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A plaque and lapel pin are awarded for a donation of $500 or more to the Richard "Dick" Neiderhauser Fund for research into Age-related Macular Degeneration (AMD) and allied retinal diseases.

Richard "Dick" Neiderhauser Fund for Research into AMD and Allied Retinal Diseases

 Date Submitted: _________________

Your Name:  _________________________________________

Your Phone: _________________________________________

Your e-mail:_________________________________________

Lion District (if applicable): _________

PLEASE PRINT SO ENGRAVING IS CORRECT ON THE PLAQUE

Donor or Club name: _________________________

Recipient: ______________________________________________

In Honor of: ____________________________________________

        or

In Memory of: ___________________________________________

Address (Street 1): _______________________________________

Address (Street 2): _______________________________________

City: ___________________________ State: __________________

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.