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2. 
3. Fort Myers Beach Memorial Bench Request Form
5. Applicant Information
7. First Name*
8. Last Name*
10. Telephone No*
12. Mailing Address*
14. City*
15. State*
16. Zip*
18. Email Address*
20. * Preferred Location (please check one)*

    1. Bay Oaks
    2. Beach Access - currently unavailable

    *  An alternate location may be required if space is no longer available at the requested location

22. Proposed Wording for Memorial: *

    The memorial area is approximately 11” x 34” and can accommodate up to 3 lines of text 

24. Cost: $565 per bench PLUS $4.00 per letter of inscription
26. RELEASE: I understand gifts to the Town of Fort Myers Beach are considered outright and unrestricted donations. I agree that if the Memorial Bench is damaged intentionally or unintentionally, or needs to be removed for any other reason, the Town of Fort Myers Beach may remove the bench at its discretion. I understand that I am responsible for keeping contact information current if I wish to receive future correspondence related to the Memorial Bench.
28. Applicant Signature

    Your signature will be required in person upon payment.

29. Application Date*
    Application Date
33. FMB PUBLIC WORKS DEPARTMENT USE ONLY
34. Approved by:
35. Date:
    Date:
37. Bench Cost:
38. Inscription Cost:
39. Total Cost:
41. Paid:

    1. Cash
    2. Check
    3. Credit Card
42. Check Number
43. CC Authorization #
45. Date Ordered:
46. Date Installed:
47. Staff Initials:
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field