Isle of Wight Council

	The Memorial Leather Panel Scheme 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 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

	Please prepare and place on continuous display in the Book of Remembrance Room for an initial period of seven years a MEMORIAL PANEL in BLUE LEATHER, lettered in gold with the following wording:
	Please use block letters as mistakes cannot be rectified once a panel is completed

	Names only. Maximum 21 LETTERS only
	Maximum 27 letters per line
	Maximum 27 letters per line
	Date of death of deceased	(dd/mm/yy

The fee of£282.00  will be required when submitting this application The fee is not refundable should the application be withdrawn or refused.

I enclose cheque/postal order/cash to the value of �...................................... (made payable to Isle of Wight Council)

	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..................................................................

	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
	Memorial Leather Panel	£282.00	AF	67850732012

Date printed: 08/03/2013