City of London - Commemorative Bench Application Form

Note: Fields marked with ★ are mandatory.

We are committed to providing a fully accessible application process. Please let us know if you require any accommodation: accessibility@london.ca.

Please complete all fields in this application. If you have questions, please contact memory@london.ca.

Contact Information - This person will be the main contact for future correspondence

Donor Name

Address

City

Province

Postal Code

Primary Phone Number

Alternate Phone Number

E-mail

Name of Honouree

Location Request

Primary Pre-approved Bench Location and Park Name:

Secondary Pre-approved Bench Location and Park Name (NOTE: Your secondary location request must be different than your primary request):

Locations are on a first come first served basis.

Plaque Wording Request

Plaque can have a maximum of 13 lines, 50 characters per line including spaces:

Payment Information

Once the City has received your application form, an electronic invoice will be emailed to the donor. Payments can be made via Cash, Debit, Visa, or Mastercard. Payments can be made in person at selected locations, by phone, or online. Additional information will be available on the electronic invoice.

Donations provided through the City of London’s commemorative program are eligible for a charitable receipt. If you have any questions regarding the charitable receipts, please contact: financialservices@london.ca.

Do you require a charitable receipt?

Questions about the program can be directed to Megan Rex, Parks Project Coordinator, at mrex@london.ca or 519-661-2489 ext. 4257.

Notice of Collection
The personal information on this form is collected under the authority of the Municipal Act, 2001 and will be used to assist Parks Planning in administering the Commemorative Bench Program. Questions about this collection may be referred to the Manager, Parks Planning and Design, 267 Dundas Street, 3rd Floor, London, ON; Tel: 519-661-2489 ext. 5067.

Note: If the form does not appear to submit, please open each section and confirm that there are no issues or missing required fields.