Request for Birthday Plaque


Name of Person (as it will appear on the plaque):

Please check applicable box:
90th Birthday 95th Birthday 100th Birthday 105th Birthday
Actual Birth date:
Year Month Day
Address of Celebrant (Mississauga Residents Only):


Name of Contact Person:


Address of Contact Person:

Phone Number of Contact Person:
Home Phone:
Work Phone:
Email:
Work Fax:
Date of any Special Celebration (party):
Year Month Day
Date Requested:
Year Month Day
Any special instructions/requests:

Please allow six weeks, you will be notified by phone to arrange for pickup.