DISTRICT 33-A LIONS

SIGHTMOBILE, INC.

NOTE: Scheduling request forms to reserve the Sightmobile for your club must be filled out in duplicate. One copy is

to be mailed to the scheduling chairman no less than 90 days in advance of the date to be used. The second copy is to

be retained for your records. You may call the scheduling chairman to check on the available dates, however a

completed request form must be received by the scheduling chairman in order to reserve the Sightmobile.

Application Date:_____/_____/_____

Dates Requested: _____/_____/_____  to _____/_____/_____

Alternate Dates: ______/_____/_____ to _____/_____/_____

USE:  Screening _____ Parade _____Public Relations ____ School: _____

CLUB NAME:__________________________________________________________

CLUB PRESIDENT:                                                                                            Phone (     ) _____ - ________

Email Address:

Contact Person:_________________________________                                   Phone (     ) _____ - ________

Address: _____________________________ Town: _______________Zip: _________

Email Address:

SCREENING LOCATION

Location: ______________________________________ Town: ________________________

Driver: (required)___________________________________________ (from approved list)

Email Address:

Cell Phone:

>> Pick up Date: _____/_____/_____  Time _____: _____ AM _____ PM _____

>> Return  Date: _____/_____/_____  Time _____: _____ AM _____ PM _____

Upon receipt and review of this request form, your club President or Secretary will be notified as to its

disposition. Requests will be approved according to the earliest postmark on a request basis.

DONATION AMOUNT: $ _______.____

While there is no charge for the use of the Sightmobile, it is through your club's generosity that we are able to

maintain and operate YOUR Sightmobile.  THANK YOU