Isle of Wight Council

	Planter Plaque and Posy Vase Application Form
	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. The plaque will remain in position for 10 years, and you may renew or relinquish the dedication after this time. The Council reserves the right to amend as may be necessary, or to refuse any inscription which is considered unsuitable.

Applicant Details

	Title
*	Forename
	Middle name/Initials
*	Surname

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

	Plaque to be placed in:	Babies and Children's Garden of Remembrance
	In Memory of:
	Section Required	Spring  Summer  Autumn Winter

Please complete the boxes for the inscription required, following the instructions below.

	Line 1 (Name)	(Max. 17 characters)
	Line 2 (Dates)	(Max. 25 characters)
	Line 3	(Max. 25 characters)

The fee of £261.00  will be required when submitting this application The fee is not refundable should the application be withdrawn or refused.

In order to ensure that an inscription will fit onto the granite tablet, please note the following information: 1. The name uses a larger typeface than the remainder of the inscription therefore it may not exceed more than 17 letters and spaces per line. The name should be confined to the top line. 2. Because of the fixing holes in the centre please use the middle line for dates only in either of the following formats: (a) 1920 - 1993, or (b) 12.3.1920 - 11.10.1993 3. The lower line can have up to 25 smaller letters and spaces for your own message. 4. Do not forget to include the spaces in your inscription. 5. If you are completing this form by hand please note that the inscription must be clearly written in block capitals. We are unable to accept responsibility for any incorrect inscription due to illegible or ambiguous writing. LINE 1 - Name only up to 17 letters and/or spaces LINE 2 - Dates only in format as given above LINE 3 - For your own short message. Up to 25 letters and/or spaces Please do not use any more letters and/or spaces as these are the most that will fit on. We reserve the right to alter or amend an inscription as necessary to comply with the above guidelines.

FOR OFFICE USE ONLY

	Paid: �......................	Receipt No:.........................	Date:......................
	Ordered:.....................	Order No:.....................	Delivered:.....................

Renewal Due................................

Renewal Notice Sent....................

Renewed/Relinquished:....................................................

	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
	Planter Plaque and Posy Vase Fee	£261.00	AF	67850731002

Date printed: 08/03/2013