INTERNATIONAL YOUTH CAMP
MULTIPLE - 322, DHANBAD, INDIA

December - 24-30, 2003

OFFICIAL REGISTRATION FORM

Name :_________________________________________________________________________

Address :________________________________________________________________________

_______________________________________________________________________________

City: _____________________PIN :________________ State / Country :____________________

Telephone :________________________________Fax:__________________________________

E-mail :________________________________________________________________________

Date of Birth :___________________Male :____________________ Female :________________

Education :_____________________________________________________________________

Hobbies :______________________________________________________________________

Special Interest (if any) :__________________________________________________________

Why you want to attend the Camp :__________________________________________________

Camp attended previously, if any :___________________________________________________

Registration Fee :- $ / Rs.______________ By DD No. :______________ Bank_______________

Sponsored by Lions Club of :_______________________________________________________

District :____________________ Multiple :_____________________ Club No :_______________

Proposed by Lion :_____________________________ Post :_____________________________

Address :______________________________________________________________________

Telephone : ____________________________________________________________________

E-mail :_______________________________________ Signature :________________________

Seconded by : Lion __________________________________Post :________________________

Address :______________________________________________________________________

Telephone :____________________________________________________________________

E-mail :_______________________________________Signature :________________________

I am fully aware of Lions International Youth Camp Board Policy and accepting the same. All the information given above are correct to best of my knowledge.

(Signature of Applicant)

Return to :-
JAGDISH MUNDRA, DG 322A
SHIV-SADAN, LUBY CIRCULAR ROAD,
BEHIND WOMEN'S COLLEGE,
DHANBAD-826001,INDIA

Please use Separate Form for Each Youth (This blank form can be photocopied)