Memorial Bench FORM

Memorial Bench FORM image
Memorial Bench Donation Form
Bench application must be submitted together with full payment to “Penn’s Prairie at Tri-municipal Park, Inc. (TMP Inc)” located at 134 N. Hoffer Avenue, PO Box 54, Centre Hall, PA 16828-0054 Once the application is reviewed and accepted, an order will be submitted.  Engraving proof must be approved by the donor before the order is finalized. 
Donor Information
Name ________________________________________________________________________
Address _______________________________________________City___________________________
State ____________________Zip Code______________ Telephone number________________
Email Address __________________________________________________________________
Bench Information
This bench is being donated in recognition of _________________________________________
Choose the Wording for Engraving and Clipart
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Overall cost: Includes the purchase of one 6-foot memorial bench, shipping, installation and upkeep in agreed upon location for a period of 5 years for $1500.
Engraving add $150
Donor signature __________________________________ Date ___________________
Park and Recreation Use Only----------------------------------------------------------------------------------
Date received __________ Payment amount _______ Board Signature ______________

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