PEKIN LIONS CLUB

      CHRISTMAS BASKET DRIVE

RECIPIENT NOMINATION FORM

All names must be received by Dec 1

I nominate the following family to receive a food basket:

Last Name____________________First Name__________________

Street_________________________________Apt #_____________

City_________________Zip___________Phone #_______________

No. in Family__________Ages of boys:__________girls:___________

Means of Support:_________________________________________

_______________________________________________________

Sender's Name_______________________Phone#_______________

Sender's Signature_________________________________________

Mail to:  Lions Christmas Baskets, P.O. Box 751, Pekin ,Il  61555-0751

               Call 477-1052 for more information

               the Lions Club cannot take contributions over the phone