Contact Information 
 
 
Primary Donor
 
 
 
 
 
First Name*
 
 
Last Name*
 
 
Language Preference*
 
 
Email*
 
 
Telephone*
 
 
 
Street Address*
 
 
City*
 
 
Province*
 
 
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 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 phone at 613-239-5678, or via email at plaque@ncc-ccn.ca.