Commemorative Bench Program Application Form

Please fill in the following information:

Name (First and Last Name):*

First NameLast Name

Date:*

Date

Birthdate: (DD-MM-YYYY)*

Date

Complete Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

Format: (000) 000-0000.

Email:*

example@example.com

Secondary Contact Name:*

Secondary Contact Phone Number:*

Format: (000) 000-0000.

Bench Information

Donation Amount: $5,000.00 - covers the cost of the bench, plaque, installation, maintenance and repair of the bench for a duration of approximately 10 years. Includes 1 replacement bench and plaque within the lifetime of the bench.
Location Requested: Commemorative benches are to be installed in pre-approved locations. If required, St. Clair Township has the right to remove and relocate a commemorative bench. Please select the location you would like the bench to be installed.

Please specify the “other” location where you would like the bench installed:

Plaque Information: Please enter your text on the lines below, using upper- and lower-case lettering as desired. Ensure all information submitted is accurate. Commemorative plaques are ordered by the St. Clair Township, and a proof will be provided for donor approval.

Line 1:*

Line 2:

Line 3:

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Commemorative Bench Program Application Form

SECTION 1: CONTRIBUTOR INFORMATION

SECTION 2: COMMEMORATIVE BENCHES-DUE MARCH 31ST ANNUALLY