Please copy this request and send to a director or to the Organ & Eye Bank directly



Lions Organ and Eye bank
Of District 2-e2
Life membership request


Lions Club of _____________________________

Contact Lion _________________________________

Date of Request:___________________

Club Address:_____________________________

Phone Number: _______________________________

Presentation Date: _________________


Wishes to purchase the following honorary life memberships:

Print Name for Award

Title Level* Amount

Mail or Deliver Date on Award







Membership Level* Honoree Receives Amount
LIFE Plaque and Pin $ 125.00
SILVER Plaque and Pin $ 500.00
HELEN KELLER Award and Pin $1000.00

Return request to any Director of the Lions Organ and Eye bank.