Commemorative Bench Dedication Form

Applicant Name
Address Address
Street Address Apt./Unit/Suite # City Province Postal Code
Phone Phone - ### - ### ####
Email
Plaque Inscription (Maximum 120 Characters, includes spaces and punctuation)
(Common Phrases Include: “In Loving Memory” or “In Tribute to” or “To Commemorate”)
Maximum of 120 characters allowed. Currently Entered: 0 characters.
Examples:
Preferred Bench Location
Notice of Collection

All personal information on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act, 2001 and will be used for the purposes of the Commemorative Bench Dedication Form. Questions regarding this collection may be directed to the Clerk, 905-775-5366, 100 Dissette Street, Unit 7 and 8, Bradford, ON L3Z 2A7.