South Dakota Lions Eye Bank


I/We pledge to the "To Share, To Hope, To Dream ... Life" Capital Campaign.

Amount of Gift: $

Initial Payment: $

Pledge Balance: $ 

*Name:    

*Address: 

*City:    

*State:   

*Zip:     

*Email


    I/We prefer to pay the balance over

three years
            OR
Five Years
as follows:

Monthly Quarterly Semi-annually Annually

I/We will make our first pledge payment on (month/year).

Signature(s):

Campaign Volunteer:

Please type your name as you would like it to be recognized

(i.e. John Doe or John Doe Family or ABC Printing)

Transplant Recipient Donor Family Member
Lions Member Lions Club/other service club
Eye Bank Friend


Payment Options

Method of Payment
Check/Cash
Credit Card
Automatic Withdrawal
Stock or Mutual Fund
My company will match my gifts to the campaign.

   Company Name:
          Comments:

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