COMPLETE THIS FORM AND RETURN TO MID-SOUTH LIONS OFFICE 930 MADISON AVE, SUITE 101, MEMPHIS, TN 38103

NAME (as it will appear on the trophy)____________________________________________________ CLUB NAME (as it will appear on the trophy) _____________________________________________ WHO WE ARE SENDING THE AWARD TO:______________________________________________ ADDRESS (where to send the award – NOT A PO BOX)_____________________________________________

CITY ST & ZIP _____________________________________________DISTRICT _______________ DALSTROMS THIS RECIPIENT HAS ALREADY RECEIVED __________ DATE NEEDED _________________

Named in honor of Mid-South Lions’ first president, the Dalstrom Award is presented only by Lions Clubs, Districts and Multiple Districts by making a minimum $1,000 contribution to Mid-South Lions during one Lions year.

Edwin Dalstrom

MID-SOUTH LIONS 930 MADISON AVE, SUITE 101 MEMPHIS TN 38103

Progressive Award (2)

Progressive Award (3)