Required fields are marked with asterisks (*)

Commemorative Bench Program

Please fill complete this form if you would like to purchase a commemorataive bench to honour a loved one or outstanding member of the community. Your contribution to the Township of Essa Commemorative Bench Program is a thoughtful and unique way to honour a special person or organization, and contributes tremendously to the community.

Name of Applicant

Mailing Address of Applicant

Postal Code

Phone Number

Email Address

Name of Preferred Park for Placement of Commemorative Bench

Inscription to Read (3 lines maximum, 45 characters per line)

Commemorative Bench Agreement between Essa Township's Parks and Recreation Department and the Purchaser

Benches will only be installed between the months of May 1st and August 31st
The bench location will be mutually agreed upon between the Township of Essa's Parks and Recreation Department and the Purchaser. The Township reserves the right to the location's final decision
The cost of the bench and plaque must be paid in full prior the bench's installation
The Township reserves the right to approve the plaque's inscription
The bench will be of the same selection as all Townshpi benches to ensure uniformity

Total Cost for Bench:

$500.00

How will you be paying?

In person by attending the Administration Centre at 5786 County Road 21, Utopia

By mailing my cheque to the Administration Centre, 5786 County Road 21, Utopia

By submitting an Electronic Funds Transfer Form on the Township's website

Date of Application

Signature of Applicant

Clear