Application for Knight of the Blind

CONNECTICUT LIONS EYE RESEARCH FOUNDATION, INC.

APPLICATION FOR

KNIGHT OF THE BLIND

HIGHEST HONOR FOR LIONS OF CONNECTICUT

RECIPIENT

Please Print Clearly Exactly as Name Should Appear on Plaque.

Is this a personal donation?

[ ] Yes

[ ] No

[ ] Recipient as 
 yet unnamed

Individual Name: _____________________________________________________

Address: _____________________________________________________________

City: _______________________________ State: _________ Zip:___________
Lionistic Affiliation.  Club Name _____________________ District _____
Check here if this is a Memorial Knight of the Blind [ ]
(Print name, complete address and relationship to deceased, or
 individual to whom the plaque is to be presented.)
Name: ________________________________________________________________

Address: _____________________________________________________________

City: _______________________________ State: _________ Zip:___________

DONOR

Complete ONLY if different from recipient. If more than a single donor, please provide a list of donors and amounts on separate page.

Name of Donor: _______________________________________________________

Address: _____________________________________________________________

City: _______________________________ State: _________ Zip:___________

Lionistic Affiliation.  Club Name _____________________ District _____
This donation is from: (check one) 
[ ]Individual [ ]Club [ ]District [ ]Multiple District [ ]Other 
Is this award a surprise to the recipient? [ ]Yes [ ]No
Please indicate where you would like the award presented:
[ ]Club Meeting [ ]Mid-Winter Conference [ ]State Convention [ ]Other

Name of Contact Person: ______________________________________________

Telephone number of contact person ___________________________________

Special mailing instructions _________________________________________

(Please include both pages when using this version of application)

DONATION
Knight Pledge* $1,000 or more $ _____________	Yearly Pledge
Ruby Knight Pledge $2,500 or more $ _________	1^st year __________ 6^th year __________
Emerald Knight Pledge $5,000 or more $ _______	2^nd year __________ 7^th year __________
Sapphire Knight Pledge $7,500 or more $ ______	3^rd year __________ 8^th year __________
Diamond Knight Pledge $10,000 or more $ ____	4^th year __________ 9^th year __________
* A Knight pledge can be payable over a period not to exceed 5 years.	5th year __________ 10^th year __________

[ ]Full Payment [ ]Partial Payment [ ]Completion of Installments

Knight of the Blind Award is not conferred until contribution totaling
the amount checked above is received at the Foundation office.

Signature ________________________________________ Date _____________

Please return to:

CT Lions Eye Research Foundation, P. O. Box 9268, New Haven, CT 06533