Leo To Lion Certification Form
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1
2LEO TO LION CERTIFICATION
AND YEARS OF SERVICE TRANSFER FORM
DIRECTIONS
Complete this form to do one or more of the following (check all that apply):
I
Request a Leo Completion of Service Certificate. Complete section I.
I
Request that my Leo years of service be credited to my Lions record. Complete section II.
I
Request a charter/entrance fee waiver if joining a Lions club. Complete section III.
B SIC INFORM TION
Basic information and signature must be completed with all requests.
Former Leo’s First Name: __________________________________ Last Name: ___________________________________
I
I
Gender:
M
F
Date of Birth: ________/________/__________ (Required)
MM
DD
YYYY
Email address: _________________________________________________________________________________________
Former Leo Club Name: _________________________________________________________________________________
Leo Member Join Date (month/year): ________________ Leo Member Termination Date (month/year):______________
I
I
I
Lions Member Status:
New Lions Member
Existing Lions Member
Not a Lion
Complete the following if applicable:
Lions Member Number: ____________________________ Lions Club Name: __________________________________
Lions Club Number: ________________________________ District: ___________________________________________
y signing this form, I certify that all information is correct.
Former Leo’s Signature: ____________________________________________ Date: ___________________________
SECTION I. LEO COMPLETION OF SERVICE CERTIFIC TE
In October 1996, the International Board of Directors approved a special certificate that can be given to any Leo in
good standing, who terminates membership in a Leo club, for any reason. The purpose of the certificate is to recognize
a Leo’s service to the Leo club and community. All information and signatures must be provided or certification will be
delayed. Certificates are not available to former Leos who terminated Leo membership prior to October 1996.
Sponsoring Lions Club
y signing below, I certify that the former Leo mentioned on this form served as a Leo during the timeframe indicated,
in a Leo club sponsored by my Lions club.
Lions Club Name: ______________________________________________ Club Number: _________________________
Lions Club Officer’s Name: ______________________________________ Title: _________________________________
Signature: _____________________________________________________ Date: _________________________________
The remainder of this application (section II. and III.) must be certified by the district governor, guiding Lion or
club secretary before the Leo to Lion Program dues discount and/or years of Leo service will be applied.
SECTION II. CREDIT FOR LEO YE RS OF SERVICE
Current and former Leos must have been a Leo for at least one year and one day to receive credit for their Leo years
of active service as part of their Lions Club membership histories. Years of Leo service to be credited to Lions’
membership record: ____________________________________________________________________________________
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