Commemorative Bench and Tree Program Donation Form

All Donations will be evaluated by the Township prior to acceptance to determine whether the Donation meets the requirements of the Township’s Donation Policy.

Thank you for your interest in the Commemorative Bench and Tree Program. Your donation will provide a lasting tribute to a loved one while enhancing our community spaces.

A minimum donation of $20.00 is required to receive a donation receipt. The Township will issue an Official Donation Receipt in the name of the Donor for an Eligible Donation accepted by the Township and made payable to the Township within 7 business days from the date that the Donation clears the bank. The Official Donation Receipt will be issued electronically or by mail to the addresses provided on this form.

Name of Donor *

First

Last

Mailing Address of Donor *

Address Line 1

Address Line 2

City

OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvince

Postal Code

Phone Number of Donor *

Email Address of Donor *

City of Donor *

Backup Contact Information Name *

First

Last

Backup Contact Mailing Address *

Address Line 1

Address Line 2

City

OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonProvince

Postal Code

Backup Contact Phone Number *

Backup Contact Email Address *

Backup Contact City *

Donation Options: *

• Commemorative Bench & Plaque – $2,500
• Commemorative Native Tree & Plaque – $1,350

Select the purpose of the commemorative bench or tree. This will appear on Line 1 of the Plaque Inscription: *

• In Memory of
• In Tribute to
• To Commemorate
• In Honour of
• In Celebration of
• Other, please explain

Donors will be acknowledged with a 6-inch by 3-inch commemorative plaque which will be flush mounted on the commemorative item. The commemorative plaque will recognize the commemoration and an inscription approved by the Township. Plaques will include two lines of writing, with a maximum of 20 characters per line.

Other: *

This will appear on Line 1 of the Plaque Inscription and can be a maximum of 20 characters.

Line 2 of Plaque Inscription (maximum of 20 characters) *

Example: John Doe Family. Township staff will approve all final plaque wording.

Commemorative Bench & Plaque

Price: $2,500.00

Commemorative Native Tree & Plaque

Price: $1,350.00

Credit Card *

Card

Name on Card

Submit

Personal information on this form is collected under the authority of the Municipal Act and is maintained in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Questions regarding the collection of this information may be directed to the Township Clerk’s office.

The Township of Puslinch is committed to providing accessible formats and communication supports for people with a disability. If another format would work better for you, please contact the Township Clerk’s office for assistance.