Memorial Bench Program Application - Township of Southwold

Required fields are marked with asterisks (*)

Application for Memorial Bench Program

Establish a living legacy with a memorial bench. Our program offers donors the chance to dedicate a bench in memory of a loved one or to commemorate a member of the community.

Fee: $2,500.00

First Name:

Last Name:

Would you like a donation receipt?

Yes

Address:

Town:

Postal Code:

Contact number:

Email address:

This form may contain personal information as defined under the Municipal Freedom of Information and Protection of Privacy Act. This information is collected under the legal authority of the Municipal Act, 2001, S.O. 2001 c.25, as amended. This information will be used and maintained by the Township of Southwold to process the request for a memorial bench. Questions regarding this collection may be directed to the CAO/Clerk, 35663 Fingal Line, Fingal ON N0L 1K0, 519-769-2010 or by email to cao@southwold.ca.

Commemorative Plaque Wording (Up to 4 Lines, 28 characters/spaces per line, subject to approval by Township of Southwold):

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Application for Memorial Bench Program