MEMORIAL TREE/SHRUB  APPLICATION FORM

	If not submitting on-line please return completed form to: Isle of Wight Crematorium Station Lane, Whippingham, East Cowes, Isle of Wight PO32 6NJ Telephone (01983) 882288 / Fax (01983) 883010
*	Please contact the crematorium on 01983 882288 if you would like any help filling in this form, or would like more information on the memorial options available. The fee is not refundable should the application be withdrawn or refused. Please Note – in the first six months after the date of cremation, only the person who applied for the cremation may purchase a memorial. If you are not the person who applied for the cremation and wish to purchase a memorial within the first six months you must provide the written consent of the person who applied for the cremation.   Please tick this box to confirm you have read and accept the terms and conditions

*	Memorial tree to be bought and planted in the crematorium Memorial shrub to be bought and planted at the crematorium.	Cost  (Fee for a memorial tree to be bought and planted in the crematorium)
		Cost  (Fee for a memorial shrub to be bought and planted at the crematorium)

Applicant Details

Title

--- Mrs Mr Miss Ms Sir Lord Lady Dr Prof Rev Other

other title (please specify)

*	Forename
	Middle name/Initials
*	Surname

*	Building/house name/number
*	Street address
*	Town name
	County
*	Postcode
	Tel number (include area code)
	Email address
	Fax