Western Pennsylvania Lions

Hearing Foundation

Lions of Pennsylvania Foundation Fellowship Application

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Western Pennsylvania Lions Hearing Foundation

APPLICATION
WESTERN PENNSYLVANIA LIONS HEARING FOUNDATION FELLOWSHIP
The following is application for the Western Pennsylvania Hearing Foundation Fellowship can be filled out digitally simply by clicking in each field and typing your response prior to printing. A blank copy of the form can also be printed.
Recipient Information:
  1. Name (exactly as it should appear on the plaque)

  2. Address
  3. Contact
  4. Is the Recipient a Lion?

Donation Information
  1. Address where the WPLHF Fellowship will be sent:
  2. Name

  3. Address
  4. Contact
Donor Information:
  1. A donation of $250 is required to qualify.
  2. Name

  3. Address
  4. Contact
  5. Type of Donation?
  6. Make checks payable Western PA Lions Hearing Foundation. Please mark the memo line WPLHF Fellow. Please allow 2-4 weeks.    
Official Use:
  1. Mail To: PDG Lance H. Remic
    122 Country Lane
    Export, PA 15632
    724.309.6750
    lremic@hotmail.com