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 ______________________________________________________
