Century Plaque Program Application FormCentury Plaque Program Application Form
__________________________ ____________________________________
Applicant’s Name Applicant’s Address
__________________________ ____________________________________ Applicant’s Phone Number Applicant’s Email Address
__________________________ _____________________________________
Property Owner’s Name (if different from Property Address for proposed plaque
applicant)
__________________________ _____________________________________
Property Roll Number (this can be found Year the structure was built
on your tax bill)
___________________________ _____________________________________
Applicant’s Signature Date
By signing this Application Form, the Applicant agrees to install the Plaque in accordance with the following guidelines:
•Plaque must be attached to the original structure on the property
•Plaque shall be installed by the applicant
•The Town of Tillsonburg releases any responsibilities for damage done to the
plaque once released to the applicant
•The Town of Tillsonburg does not provide any refunds for lost or damagedplaques once released to the applicant
•Plaque must conform to the regulations set out in the Oxford County addressing
policy
Please submit completed Application Form to:
Town of Tillsonburg
Attn: Laura Pickersgill
200 Broadway, Suite 204
Tillsonburg, ON N4G 5A7 lpickersgill@tillsonburg.ca
Please print all information so that it is clearly legible.
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