International Association of Lions Clubs

Personal Info:

Title:

First Name:                       MI:     

Last Name:     Suffix: 

Nick Name:  

Home Address:  

Home Country:  

Home Phone:      

Employment Info

Occupation:  

Occupation Title: 

Business Address:

Business Country:

Business Phone:   

Business Fax:       

How long in present occupation?

Family Info

Spouse's Name:           

Spouse's Occupation:  

Organizational History:

Are you a former Lions Club member?   No  Yes

Reason for leaving: 

Other Service Organizations do you belong to:

Committee Preferences

I express a preference to serve on the committee or committees checked below.

Administrative committees:

Attendance                                      Constitution and by-Laws

  Convention                                     Finance

  Greeter                                           Leadership Development

  Lions Information                            Membership

  Program                                          Public Relations-Bulletin Editor

Activities Committees:

  Diabetes Awareness                        Sight conservation 

  Youth Outreach                                    and work with the blind

  Hearing Conservation and                Environmental Services

       Work with the deaf                          International Relations

  Leo Club Program                           Youth Exchange