Report of Election of Lt. Governor-elect

Lt. Governor-elect, Please complete this form and click the submit button once complete.

Term (Year) as Lt. Governor-Elect

Name:

First Last

Member #

Club

Division:

Spouse/Partner's Name:

First Last

Name as you would like it to appear on your name badge and in the directory:

First Last

Occupation:

Name as your spouse/partner would like it to appear on their name badge and in the directory:

First Last

Preferred Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

(It should be a street address, not a post office box number, to receive packages from the District and Kiwanis International quickly and economically).

Business Phone:

Cell Phone:

Email Address:

Served as Club President(s):

Club(s) Year(s)

Other Positions held in Club:

Position Title(s)

Positions held in Division, District or International

Number of years in Kiwanis Membership:

Date First Joined Kiwanis:

Held Kiwanis Membership in Following Club's: (Give Dates if possible)

Number of Conventions attended:

District:

International:

Mid-Year:

Do you have Life Member Status?

Kids Need Kiwanis

Report of Election of Lt. Governor-elect

Number of Conventions attended: