Lions Club Name: __________________________________________________________________________ Member Sponsor: __________________________________________________________________________ First Name: ________________________MI: _____  Last Name:________________ Suffix:____________ Gender:  Male  Female Occupation: __________________________________________________ Date of Birth: ______________________________Spouse’s Name: ________________________________ Address: __________________________________________________________________________________ City: ______________________________State: ________Zip:______________Country: ______________ Phone: ____________________________Email: ________________________________________________ Please review qualification criteria and fees for the following: I am a:  New Member   Former Member  Transfer Member Member Number: __________________________ (If unknown, email stats@lionsclubs.org) Previous Club Name:________________________________Previous Club Number: ____________  Family Member  Student Member  Current or Former Leo  Young Adult
Enclosed is $__________as an entrance fee, in addition to $ __________for international, multiple district, district and club dues. 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:________________________Type your paragraph here.



Williamsburg Host Lions Club
UA-73173733-1