Isle of Wight Council

Memorial Wall Tablet Application Form

*	The giving of false information may result in registration being refused or revoked, and the local authority reserve the right to make such further enquiries arising out of this application as they may consider desirable. The fee is not refundable should the application be withdrawn or refused. Please note that the Tablet will be placed in the next available space on seven/fourteen year scheme. Letters will be sent before renewal date is due. 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 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. You may be required to sign a copy of this application at a later date
	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

Applicant Details

	Title
*	Forename
	Middle name/Initials
*	Surname

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

Name of deceased

INSCRIPTION FOR WALL TABLET

	Line 1
	Line 2
	Line 3	(max. 12 characters)
	Line 4
	Line 5

Fee payable for granite wall plaque at the crematorium

*	Fee for 7 years Fee for 14 years	Cost for 7 years
		Cost for 14 years

	Declaration
	I declare that I have checked the information given on this application form and to the best of my knowledge and belief it is correct. I understand that a false or misleading statement, or that withholding relevant information, may result in the refusal or revocation of the licence and\or may render me liable to prosecution. Signed............................................................... Name................................................................ Date..................................................................

FOR OFFICE USE ONLY

	Receipt number/Date .....................................................................
	Order number/date .........................................................................

	Delivered: .................................	Fixed:...............................................
	Informed Applicant (Letter/Phone).......................	Cremation No:............................................
	No of tablet:.......................................	Renewal date:........................................
	Renewal letter sent.......................................	Renewed/Not Renewed:...............................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

	Product	Cost	VAT code	GL Code
	Granite Wall Plaque - 7 Years	£343.00	AF	67850731002
	Granite Wall Plaque - 14 Years	£496.00	AF	67850731002

Date printed: 08/03/2013