LIONS DISTRICT 14-M DISASTER FUND APPLICATION

Club President:

Name____________________________________________

Address__________________________________________

_________________________________________________

Phone Number____________________________________

Date_____________________________________________

To: District 14-M Disaster Fund Chairperson requesting needed emergency assistance.

To request assistance from the 14-M District Disaster Fund, please submit this form letter to comply with the following regulation as set forth in the Disaster Fund Guidelines.

“The request for needed assistance must be submitted by the President of the Lions Club within District 14-M located in the area from which such needed assistance is requested. The President will serve as the Chairperson of the appointed committee to investigate the needed assistance being requested prior to forwarding.”

As President of the _______________________________________Lions Club and following investigation by the appointed committee, I ________________________

__________________________hereby submit the following:

Name_____________________________________________

Address___________________________________________

__________________________________________________

Marital Status Single_______ Married_______

Write an informative description explaining facts pertaining to the nature of needed assistance, such as the encounters, which would be cause for assistance. Include any such assistance your local Club has given. You may use the reverse side of this form for the needed information.