Memorial Bench Form

Name*

First NameLast Name

Email*

example@example.com

Phone number*

Address*

Street Address

Townland

TownCounty

Postcode

Please specify the memorial*

Where would you like the memorial to be located?*

The location must be Council land or park. Please provide as much information on the location as possible.

Please supply the name for the plaque*

First NameLast Name

Please include a memorial message for the plaque*

Please note, Council reserve the right to approve any message. A message can have a maximum of 50 characters

(Applicant name)* will pay the sum when the memorial is approved, which is to be confirmed from the current charges indicated on the Council website or as advised by Depot administration.

A memorial bench, the Council will place the Memorial bench with plaque or plaque only in the agreed location within two months of receiving the cheque and/or plaque.
The Council will be responsible for the bench for the period of its natural life (approximately 15 years). Memorial Benches will be kept fit for purpose with minor faults being repaired and build-up of algae or grime being removed within available resources.
Once the bench has reached the end of its natural life, the bench and plaque may be removed. A request to purchase a new replacement bench can be made at the appropriate time.
The Council cannot guarantee against theft or vandalism and will not be liable not be able to replace either the bench or plaque in this event.

I understand and agree to all the conditions above and understand that when the memorial is approved, I will be contacted to pay by card or electronic bank transfer at either Gortrush or Killyvilly Depot on 03003031777, or will have to make a cheque payment.

Do you agree to the above Terms & Conditions*

I agree

In accordance with the Data Protection Act (as amended from time to time), Fermanagh and Omagh District Council has a duty to protect any information we hold on you. The information you provide on this form will only be used for the purpose of the Memorial and will not be shared with any third party unless law or regulation compels such a disclosure. For further information on how we hold your information please visit the Privacy section at www.fermanaghomagh.com

Signature*