Lions Club Name:
_______________________________________________________
First Name: ________________________ MI: _____
Last Name:________________________________ Suffix: ________
Date of Birth: ______________________________ Spouse’s Name: ________________________________
Address: ________________________________________________________
City: ______________________________ State: ________ Zip:______________ Country: ______________
Phone: ____________________________ E-mail: ________________________________________________
Please review qualification criteria and fees for the following:
I am a: New Member
Former Member Transfer Member Member Number: __________________________
Current Dues paid sem-annually are:
Single: $80.00/year
Family: $120.00/year
I accept membership into Lions Clubs International and that the standards are limited to persons of good
moral character and reputation. I recognize the importance of rendering personal service to my community
in cooperation with other civic-minded persons. I understand that membership is not valid until approved
by the club’s board of directors.
Signature:_______________________________________________ Date:_________________________
First Name: ________________________ MI: _____
Last Name:________________________________ Suffix: ________
Date of Birth: ______________________________ Spouse’s Name: ________________________________
Address: ________________________________________________________
City: ______________________________ State: ________ Zip:______________ Country: ______________
Phone: ____________________________ E-mail: ________________________________________________
Please review qualification criteria and fees for the following:
I am a: New Member
Former Member Transfer Member Member Number: __________________________
Current Dues paid sem-annually are:
Single: $80.00/year
Family: $120.00/year
I accept membership into Lions Clubs International and that the standards are limited to persons of good
moral character and reputation. I recognize the importance of rendering personal service to my community
in cooperation with other civic-minded persons. I understand that membership is not valid until approved
by the club’s board of directors.
Signature:_______________________________________________ Date:_________________________
Copyright 2009 Acme Rockets
12345 Street Address
Cityname, ST or Province 12345
12345 Street Address
Cityname, ST or Province 12345
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Henniker Lions Club: Meets Third Thursday 6:30 pm @ Daniels Restaurant