Required fields are marked with asterisks (*)

Commemorative Asset Application

Fill out this application if you are interested in donating a commemorative asset to Pembroke's parks.

For more information about Pembroke's Commemorative Asset Program, please click here (Pembroke.ca/InMemory)

Part A - Applicant Information

First Name

Last Name

Email Address

Primary Phone Number

Secondary Phone Number

What is your preferred method of contact?

Phone

Street

City

Province

Postal Code

Would you like a donation receipt mailed to you at the end of the year?

Yes