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Melvin Jones Fellowship Application

Individual Completing this Form
Name __________________________________________________________________________________________ Date __________________________
E-mail ___________________________________________________________________ Phone________________________________________________
1. Area of Giving 3. Recipient of Recognition (Individual person)
Please check one Type of recognition requested (please check one)
Area of Greatest Need Measles MJF PMJF To Be Named Later
Memorial Plaque in memory of deceased
Disaster Sight Youth
(Each choice above is eligible for MJF credit) Recipient Name (Exactly as it is to be engraved on plaque)
Other__________________________________________________________ __________________________________________________________________
(May not be eligible for MJF credit) Recipient ID# (if applicable) __________________________________________
Recipient Name_____________________________________________________
MJF Credits to be used from previous donation:
Address___________________________________________________________
*Please Note – This section should only be used if sufficient funds have
already been deposited with Lions Clubs International Foundation City_________________________________ State/Province________________
Use Credits From:__________________________________________________ Country_____________________________ Postal Code___________________
Club of Recipient
ID#:_______________________________________________________________
__________________________________________________________________
Club #____________________________ District__________________________
2. Contribution Details
For Memorial List name of MJF surviving family member to whom
Donor Name (individual, club, company, foundation) Memorial plaque will be given. (Needed for recognition letter which
accompanies plaque.)
___________________________________________________________________
__________________________________________________________________
Donor ID___________________________________________________________
Donor Club ________________________________________________________
4. Shipping Information
Donor District______________________________________________________ Please Note: Materials cannot be sent to PO Boxes.
Ship to Member ID # (if applicable)___________________________________
Amount of Contribution________________________________________
Name_____________________________________________________________
Full Payment Installment Final Installment
Address___________________________________________________________
Donors making personal donations towards MJF also receive credit as a
Contributing Member! The Contributing Membership program is an annual City_________________________________ State/Province________________
program that recognizes three levels of support: Country_____________________________ Postal Code___________________
US$20 (Bronze), US$50 (Silver) and US$100 or above (Gold).
E-mail_______________________________ Phone_______________________
☐Yes! In addition to receiving MJF credit, I would like to receive a
Recognition is sent once donation and application are received and processed at
Contributing Membership Pin for my donation. headquarters. Please allow a minimum of 15 days in the U.S. and 30 days elsewhere
for shipping.
Special Instructions/Notes
Gift Type
Make donations via the web at www.lcif.org __________________________________________________________________

US$ Check Enclosed (payable to LCIF; drawn on US bank) __________________________________________________________________
Wire/Bank Transfer (Please attach bank transfer receipt)
Lions Clubs International Foundation
Local LCI Deposit (Please attach bank deposit ticket)
Department 4547
Cash (Mail donations along with the Donor Contribution Form
Carol Stream, IL 60122-4547
to address provided) USA
The Foundation uses a lock box service to receive and process all LCIF42M EN 2/16
Tel: 630-203-3836
donations. Web site: www.lcif.org
E-mail: donorassistance@lionsclubs.org
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