Borough of Somerville - Memorial Bench Application

Donor’s Name:

Email:

Address:

Phone:

Send recognition letter to (if applicable)

Name:

Address:

BENCH, $1300.00

Preferred Location

PLAQUE: Print (legibly) what is to be engraved on the plaque, up to four (4) lines with twenty-five (25) characters per line. Punctuation and spaces count as characters. Text on plaque will appear in CAPITAL letters. Submitted wording is subject to approval.

Line 1:

Line 2:

Line 3:

Line 4:

I agree to the terms of this agreement:

Print name Signature Date

Office Use Only: Received by:

Date:

Total Paid $

Cash or Check #