Online Form - Commemorative recognition - large memorials

Selection criteria

Applications must meet one or more of criteria a) through c), and must meet criteria d).

Tick at least one or more of the following that apply:*

a) Subject of the memorial contributed more than 20 years of their life towards the development of the Town of Vic Park
b) Subject of the memorial contributed to one or more sectors of a community, e.g. sport, education, arts, culture, youth
c) Subject achieved role-model status in the wider community or achieved national or international recognition
d) Subject demonstrated outstanding levels of civic service for more than 20 years
e) Subject donated significant property or funds for community benefit

Please confirm that the following criteria are met by your application:*

f) That no other memorial to the same subject exists at the proposed location or other area of the Town of Victoria Park unless there are exceptional circumstances approved by Council.
g) Other than under exceptional circumstances approved by Council, the subject of the memorial (i.e. person nominated) shall be deceased. [Apart from those applications received for inclusion in the Victoria Park Dictionary of Biography where the nominated subject may be living but the remaining criteria for small memorials applies.]

Note - that applications initially approved by the Town may be put out to community consultation, where relevant, according to Town policy, to provide information, to enable feedback and advice on a large memorial.

Applicant name*

* Required Field.

Phone/mobile*

* Required Field.* Please enter a valid phone number

Email*

* Required Field.* Please enter a valid email address

Address

Type of recognition applied for*

Monuments such as fountains, statues etc.
Naming of Town facilities and/or buildings
Naming of parks and/or reserves
Naming of roads, lanes and rights-of-way

* Required Field.

Note - complete the appropriate section following, depending on whether your application is for a person, or an organisation/event.

Commemorative recognition: person

Please leave this section blank if your nomination is for an organisation/event and scroll down to next section.

Name of person to be recognised

Is the person still living

Yes
No

Date of birth

Date of death

Do you have a photograph of the person to be recognised?

Yes
No

If yes and it is in digital format, please upload it here

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Has permission been given by the next of kin where an application is being made to recognise a deceased individual?

Yes - please upload letter below
No - please provide reasoning below

Yes - Upload permission letter

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

No - please provide reason why you don't have next of kin permission.

Describe why this commemorative recognition should take place?

How long has/did the proposed recipient live/work or was associated with the Town of Victoria Park?

What is the proposed location for commemorative recognition of the proposed recipient? (The Chief Executive Officer will make the final decision on the location of the memorial.)

Commemorative recognition: organisation/event

Please leave this section blank if your nomination is for a person and scroll down to next section.

Name of organisation/event to be recognised

Describe why this commemorative recognition should take place?

How long has the organisation/event been associated with the Town of Victoria Park?

What is the proposed location for commemorative recognition of the proposed organisation/event? (The Chief Executive Officer will make the final decision on the location of the memorial.)

Supporting evidence

References

Please supply below the details of four current residents of the Town, their contact details and statement of support for the application. The person providing the reference cannot be related to the nominee either by blood or marriage.

Reference 1

Name

Phone/mobile

* Please enter a valid phone number

* Please enter a valid email address

Address

I support this application for commemorative recognition because (please attach document if needed):

Attach support document if needed.

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Applicant checklist

Please attach a letter of permission from the next of kin where necessary.
Ensure you have entered all details correctly and provided as much information as you can to support your application.
Attach a photograph of the person being nominated.
Ensure that you have obtained one written reference in support of your application.

Reference 2

Name

Phone/mobile

* Please enter a valid phone number

* Please enter a valid email address

Address

I support this application for commemorative recognition because (please attach document if needed):

Attach support document if needed.

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Reference 3

Name

Phone/mobile

* Please enter a valid email address

Address

I support this application for commemorative recognition because (please attach document if needed):

Attach support document if needed.

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Reference 4

Name

Phone/mobile

* Please enter a valid phone number

* Please enter a valid email address

Address

I support this application for commemorative recognition because (please attach document if needed)

Attach support document if needed.

Max File Size: 10.00 MB
Allowed File Types: .avi, .doc, .docx, .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png, .ppt, .pptx, .xls, .xlsx

Applicant's check list

Please attach a letter of permission from the next of kin where necessary.
Ensure you have entered all details correctly and provided as much information as you can to support your application
Attach a photograph of the person being nominated.
Ensure that you have obtained four written references in support of your application. These references cannot be related to the nominee either by blood or marriage.

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