Contact Information 
Primary Donor
First Name*
Last Name*
Language Preference*
Street Address*
Postal Code*
Additional Donor #1 (if applicable)
Donor 1 First Name
Donor 1 Last Name
Donor 1 Telephone
Donor 1 Email
Additional Donor #2 (if applicable)
Donor 2 First Name
Donor 2 Last Name
Donor 2 Telephone
Donor 2 Email
Additional Donor #3 (if applicable)
Donor 3 First Name
Donor 3 Last Name
Donor 3 Telephone
Donor 3 Email
More than 3 Donors
Location Selection 1:
Location Selection 2:
Location Selection 3
Can’t find your location? Check this box for assistance.
Permission for the NCC to communicate with you via email regarding this request.
Privacy statement:

The information collected in this form is required for the administration of the NCC’s Park Bench Dedication Program. In accordance with the Privacy Act, personal information collected will be used only for the purpose for which it was initially obtained or compiled, and will be accessed by authorized personnel only. Furthermore, the NCC collects and manages the personal information in this application in accordance with its Privacy Policy. The personal information will be stored in Personal Information Bank NCC PPU 80.

Note that the NCC uses an external third-party service (ClickDimensions) to transfer information about your application from its website to the NCC’s internal systems. Please note that, once you are redirected to the ClickDimensions website, its privacy policy will apply, and the NCC’s Privacy Policy will no longer apply. If you wish, you can choose to provide your information directly to the NCC by telephone at 613-239-5678, or via email at