City of London - Memory Wall Engraving 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

Message You Would Like Engraved

Example:

JOHN W. SMITH

1902-1987 BELOVED FATHER AND HUSBAND

YOU WILL BE IN OUR HEARTS ALWAYS

Name (maximum of 26 characters, including spaces)

Date and message (36 characters per line, 72 characters total including spaces for a maximum of two lines)

Payment Information

Once the City has received your application form, an electronic invoice will be emailed to the main 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.

Do you require a charitable receipt?

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 Tree 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.