TEXAS LIONS MUSEUM

AND

OFFICE FOUNDATION, INC.

Application for Everett J. Grindstaff Fellowship or Life Membership

Please check one: Fellowship ($500)

Life Membership ($100)

Donor Information:

Multiple District _________________ District _____________ Other __________________

Club Name and City _____________________________________________________________

Purchaser ______________________________________________________________________

Recipient Name _________________________________________________________________

(please print as it should appear on plaque and/or certificate)

Mailing Address ________________________________________________________________

(physical address)

______________________________________ ____________ __________

(city) (state) (zip)

Special Instructions: _____________________________________________________________

______________________________________________________________________________

------------------------------------------ Payment Information ------------------------------------

Check No. ______ payable to Texas Lions Museum and Office Foundation, Inc.

OR

Credit Card No. __________________________ Expires__________ CVV ____

Return to: MD2 Texas Lions State Office P.O. Box 294509 Kerrville, Texas 78029