Memorial Plaque Request Form

Please complete and mail this form along with payment payable to:
Bowen Island Memorial Garden Society
c/o J. Bakker
512 Rockmoyne Pl.
 Bowen Island, B.C. V0N1G2

Each Plaque cost $100.00 Canadaian Funds
payable by cheque, postal Money order or International Bank Draft

You may call 604-947-9565 for more information

Please Click Print This Page after completing the form up to the Signature Block

Name on Plaque:
Date Of Birth:
Date of Death:
Name Of Donor
Address
City
Province/State

Country
Postal/Zip Code
Phone Number
Email Address
Your Comments

Signature