Good Samaritan LCF - IV NameThis field is for validation purposes and should be left unchanged.Date of Application(Required) MM slash DD slash YYYY Name of RecipientEnter name as it will appear on the plaque.Good Samaritan Fellowship Recipient(Required) First Last Sponsoring Lion(Required) First Last Sponsoring ClubPlaque Mailing InformationClub representative or person to whom plaque is to be mailed.Club Representative Name(Required) First Last Club Representative Position(Required) Club President Club Secretary Other Club Representative Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)FaxClub Representative Email Address(Required) Date by which awards must be received. MM slash DD slash YYYY Please allow 30 days for processing.Payment & AcknowledgementMemorial Donation(Required) Yes No Progressive Fellowship(Required) Yes No The plaque will be ordered and sent to the address provided AFTER payment has been received.(Required) Acknowledge Check the box to acknowledgeClub Representative SignatureTo sign, click & hold the left mouse button or press & hold your finger inside the dashed box to draw. To clear, click the gray icon in bottom-right corner.Payment Options Mail Check for $500.00, written to Lions Charity Foundations of Southeastern Virginia Inc. and mailed to Good Samaritan Chairperson, 4241 Manchester Rd., Portsmouth, VA 23703 Credit Card Payment for $500 Good Samaritan Fellowship Price: PaymentCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name
