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LIONS INTERNATIONAL ESSAY CONTEST ENTRY FORM

Please type or print clearly. All information and signatures are required.

I. Student Information

Name __________________________________________________________________________

Essay Title ______________________________________________________________________

Age ____________ Birth Date ____________(dd/mm/yyyy) Male __ Female __

City, State, Country _________________________________________ Postcode ______________

Telephone +44.________________________

E-Mail _____________________________________

Parent or Legal Guardian Signature ______________________________________________________

School _____________________________________

II. Lions Club Information

Club Name __________________________________________________________________________

Club Number ________________________________ District Number ___________________________

President's Name _____________________________________________________________________

Telephone +44.________________________ Work Phone +44._________________________________

E-Mail _____________________________________

Address

City, State, Country _________________________________________ Postcode ______________

Club President's Signature ______________________________________________________

III. District Information

District Governor ______________________________________________________

Telephone +44.________________________ Work Phone +44._________________________________

E-Mail _____________________________________

District Governor's Signature ______________________________________________________

IV. Multiple District Information

Multiple District Council Chairperson ______________________________________________________

Telephone +44.________________________ Work Phone +44._________________________________

E-Mail _____________________________________

Council Chairperson's Signature ______________________________________________________