Memorial Bench FORM

Memorial Bench FORM image
Memorial Bench Donation Form
Bench application must be submitted together with full payment to “Penn’s Prairie Park, PO Box 207, Centre Hall, PA 16828". 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 ______________

Printable form
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