Surname
Name
Middle Name
Date of Birth (DoB)
Valid proof of DoB (Upload Aadhaar Card )
Address Residence
Office
Telephone Numbers: Residence 1
Office 1
Residence 2
Office 2
Mobile Number
Email ID
Member of LIONS CLUB OF
Date of Joining Lions Club
Membership No.
Applicant’s Signature
Introduced by
Signature
I, , MEMBER of Brotherhood Scheme, hereby nominate my
Relationship:
Nominee Name:
Nominee Age:
Date (as on):
Nominee Address:
Contact No.:
Email ID:
as the person to whom the moneys receivable by me under the Brotherhood Scheme, in the event of my death.
Date:
Applicant’s Signature:
Please Affix Passport size photo of Nominee: