Required fields are marked with asterisks (*)

Memorial Bench Application

Commemorate the life of a loved one by dedicating a memorial bench in their honour. A bench provides a lasting tribute and a peaceful place for reflection, beautifully recognizing those who have passed from our community.

The West Perth Memorial Program offers an elegant and meaningful way to honour loved ones with a dedicated bench and personalized plaque. This living memorial may provide comfort to those who have experienced loss, while offering a space for remembrance and connection.

Remember a family member, friend, or colleague who has passed away by purchasing a memorial bench with plaque in their name through the West Perth Memorial Program.

Applicant Name

Name of Person Being Memorialized.

Address

City/Town

Province

Postal Code

Phone Number

Email Address

Name for Income Tax Receipt Purposes (if different from above)

Plaque Wording (text must fit within an area of 3.25" x 3.75")

Payment information:

Payment of $2000.00 can be made by cash, debit or cheque (payable to The Municipality of West Perth) to the following: Municipality of West Perth, 160 Wellington Street, P.O. Box 609, Mitchell, ON N0K 1N0

*Please note that a 2% transaction fee applies to credit card payments over $250.99 when made at the Municipal Office.

We also accept e-transfers. Please send your e-transfer to finance@westperth.com and include "Memorial Bench" and your contact name in the memo section. For more information on how to complete the transfer, please contact the Clerk’s Department at (519) 348-8429 ext. 221 or email clerk@westperth.com.

Bench Installation: The benches are made from durable, recycled plastic, offering a sustainable option for your memorial bench. The purchaser shall discuss a location with the assistance of the West Perth Community Services Department. Potential locations for the memorial bench could include areas such as the wetlands, Keterson Trail, the Memorial Forest, Demonstration Forest, Lions Trail, or other suitable sites. These options will need to be reviewed and discussed further with the Community Services Department. Although best efforts shall be made to install the bench at the purchaser’s choice, the final discretion shall be maintained by West Perth Community Services Department.

Plaque Details: A standardized plaque will be securely affixed to the selected memorial bench. Ordering and placement of the memorial plaque will be coordinated by the West Perth Community Services Department and may take up to twelve (12) months to complete, depending on the time of year and other factors. Plaques are guaranteed for three (3) years. During this period, the Municipality of West Perth is responsible for the replacement or repair of plaques due to theft, vandalism, or other damage. If the purchaser wishes to replace the plaque after the guarantee period, a fee of $65.00 will apply to cover the cost of the new plaque and its installation.

Maintenance: The Municipality of West Perth cannot guarantee benches against acts of vandalism or damage. Should it become necessary to move, remove or replace a bench at any time for safety, or any other reason(s) deemed necessary, the Municipality of West Perth will make every effort to install the bench at the originally selected location or a similar nearby location but reserves the right to make adjustments at the sole discretion of staff. In such cases, the purchaser will be notified of any changes.

Signature

Clear

The personal information, as defined by the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA), is collected under the authority of the Municipal Act, 2001 and in accordance with the provisions of MFIPPA. Personal information on this form will be used for the purpose of the Municipality of West Perth's Memorial Bench program. If you have any questions regarding this collection, use, and disclosure of information, contact the Clerk at 519-348-8429 ext. 224 or clerk@westperth.com.