PARC Memorial Bench Application

Applicant Information
Your Name(Required)
First Last
Your Address
Street Address Address Line 2 City ZIP Code
Contact Information
How can we get in touch?
Your Email Address(Required)
Email Address Confirm Email Address
Your Phone(Required)
Best Time to Call You(Required)
Bench Location Preference
Preferred park or location (subject to availabillity)
Inscription Information
Plaque size allows up to 3 lines, 30 characters per line (including spaces). The Town reserves the right to approve inscriptions.
Line 1:
Line 2:
Line 3:
Contribution Amount: $1,000 (includes plaque and bench)(Required)
- Check
- Credit Card
- Other
Other: (please explain)(Required)
Consent(Required)
By signing below, I understand the following conditions are agreed: 1. Upon confirmation of date, the Town will consider this application at the next available Parks and Recreation Commission meeting. 2. The Town of Fairfax will install and maintain the bench as required. 3. Once approved by the Town, contributions are non-refundable. 4. Bench locations are subject to availability. 5. The Town reserves final approval of inscriptions.
Signature (Type name as electronic signature)(Required)
Date(Required)
MM slash DD slash YYYY

Applicant Information