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<br />. JAN 09 2004 09:49 FR ARTESYN ENGINEER_ING_...6.12 392 6740 TO 96514298629 <br />Oa1U'/U~ r.~ ~u.~. ..~ - - - <br />:.TJ ~btM~I~~'?~ <br /> <br />P. 12/16 <br /> <br />REQU.ST FOR LIONS CERTIFICA TES OF INSURANCE <br />.......NOTE= WE REQUIRE 7 BU81Neal.J)AVS TO PROCESS THIS REQUEST...... <br /> <br />Date 1-1-04- <br /> <br />Thla form can either be faxed or mallld to T. J. Adam. Group, LLC <br /> <br />'. <br /> <br />Addre..: 333 E. Butterfield Rd., Sm. 500 <br />Lomb'lrd,'IL 10148 . <br />Attn: "arcl Rey.. <br /> <br />CLUB INFORMATION: <br /> <br />Fad: (e30)3Ue21e1 <br />Attn: Marcl R.ye. <br /> <br />Neme of Llonl Olub ~...J1\Z~Il..-u2" L-I ~ S ./. ui7 <br /> <br />Adell"" <br /> <br />71'5*'7 ~,~ 'l:::>2..,~,~ <br /> <br />City, hte. Zip L-1Z1-S'lGi!i2-II." ~ . ,,^...J 17'" o'3>B <br /> <br />EveNT INFORMATION: <br /> <br />eVtnt IL..€ P\5>t-.h..../~ ~~~ <br /> <br />(I) of Event <br /> <br />$kI,-,~':' .~~P-v,.';L1 ,Tl'I <br />~~l2..IJl~ I-A~ <br /> <br />Loc<<lon of Evt"t <br /> <br />CERTIFICATE HOLDER/ADDITioNAL INSURED INFORMATION: <br /> <br />Certificate Holder: <br />. (P<lrty requiring <br />cer1lflcate from <br />your club) <br /> <br />~..r o~^ ~:; '~7 ~~i2-IPr--/ Ao.J~;L,A L.t:v~ <br />_ _~D j:a. .~~ L.A~\?" ~L\.'r.:>- _ <br />il'\....iv~"ei< r-",.......1 "7'? ;,t>4 <br />. <br />Ih"3-'7.:?4- 4>74'7 <br /> <br />Addlllontllnllurads: (In order to bt In eddltlonl' inturtd, tha PII1Y mutt own thl praml... on ';Which you <br />are conducting ~ur .vllnt ~ I pUbliC l:Jody Iatulna I Plt!!!It): <br />U Nont ..e!I.. Sllme al Certlftcete Holder W Different from Clrt. Holder <br /> <br />MAILING/FAX INFORMATION: <br /> <br />Requllted By: b-:ued.. ILle~<-+4l>;2.5'l <br />phone" whel'll YOIl can bll re.ched ror quelllon,: hI ~ - ~'2-1 - '9 \ 7-2- <br /> <br />bo.eJ- ~~~~'i26<I <br />-:>l C;Cj ~...... L::>;;2....V? <br />"::::"~j<--'4 ,rW-J "77 .0"3>8 <br />~F8X Num~r: '71::>'7 -"7"74- 4'7?-.:> Aj'T"""o-J: ~?.J"7 ?i....,.c:. <br /> <br />.... PI..IO r... fr.. to attach a f:Opy of 'e.t yea,. ,artlflclb If IVlllablt with Iny nece,.lry cll.ng....... <br /> <br />Send Tc (lfmaillng): <br />OR <br />