Required fields are marked with asterisks (*)

Applicant information and Dedication type

Please complete the form below, indicating the donor's contact information and dedication type of interest. Details relating to plaque wording, maintenance and repair and payment information can be found on the webpage and page two of this form.

First and last name

Street address

City

Province

Postal code

Phone number

E-mail address

Dedication Type (prices do not include hst)

Existing Park Bench with Dedication Plaque - $1680 + hst

Dedication Tree No Plaque - $610 + hst

Dedication Tree with Plaque - $865 + hst

Type of tree

Sugar Maple

Native Red Maple

Oak variety

White Spruce

Norway Spruce

Name of public park in Waterloo

Plaque wording for bench (maximum 3 lines, 12 characters per line)

Plaque wording for tree (maximum 3 lines, 20 characters per line)

Other Comments

Personal information requested on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, c.25, and will be used to assist City staff in making a decision on this Work. Questions regarding this collection should be forwarded to the Director of Environment and Parks Services, 265 Lexington Crt, Waterloo ON N2J 4A8, 519-886-2310 x30237.

Forms

Applicant information and Dedication type