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Indiana Lions Foundation is qualified under 501(C)(3) of the Internal Revenue Service code as a public charitable trust.

Nominee Information

Method of Payment
$500 or 10 credits
Nominee Name*
Spouse Name
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Is the recipient a Lion?*
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Applicant Information

Nominee Name as to Appear on Plaque*
Authorized Person*
By typing my name above, I acknowledge that I have actual knowledge of the contents of this form and I understand the requirements and further agree that this is valid and can be used as my signature.
Name of club giving fellowship