Club Number: ______________________________________ Date: __________________________________
Club Name: ________________________________________________________________________________
Please enroll as a International President’s Recognition recipient:
Name:__________________________________ Member Number: __________________________________
Address:___________________________________________________________________________________
City: __________________________________ State/Province: _____ ZIP/Postal Code: _______________
Full payment enclosed ($150 US funds or equivalent)
Club check enclosed, # ____________
Personal check enclosed, # ____________
The cost of the International President’s Recognition is $150 US payable in full at time of purchase.
All payments should be directed to:
Optimist International
Membership Department
4494 Lindell Boulevard
St. Louis, MO 63108
Phone: (314) 371-6000 • FAX: (314) 371-6006
If this subscription is to be treated confidentially, please indicate to whom all correspondence
should be directed:
Name:__________________________________ Member Number: __________________________________
Address:___________________________________________________________________________________
City: __________________________________ State/Province: _____ ZIP/Postal Code: _______________
Telephone Number: ___________________________ Country: _____________________________________
Internaonal President’s Recognion
Applicaon
