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Memorial Plaque

This application form is to request approval for the installation of a memorial plaque within City of Cockburn public open space, in accordance with the City's policy below.
Document name Downloadable files
Installation of Private Memorial Plaques in Public Open Space - PolicyPDF document


Application Process

  • The person(s) named must be deceased and have a clear connection to the City of Cockburn community.
  • Complete and submit this form for assessment. Applications are assessed in accordance with City policy.
  • If approved, City of Cockburn Fees and Charges apply
  • The city will supply and install the plaque (sample below)
  • Multiple plaques may be installed on the same park bench if demand requires
  • Once payment is received it will take approximately 3 months to complete

Fees

Standard memorial plaque fee, refer to the City of Cockburn Fees and Charges.
 
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Print Form

Application for Memorial Plaque

All fields are required except where indicated

Applicant Details

Deceased Persons details

Plaque Details (Two people can be on same plaque)

NB: Must be in the City of Cockburn
 
NB: Must be in City of Cockburn
NB: Can be first and last name or nick name, whatever is meaningful to you
Please choose a memorial plaque style from the examples shown below:
Example1
Memorial Plaque example 1		 Example 2
Memorial Example 2
Location of seat
  • Please provide the preferred park bench location you wish the plaque to be installed on. This can be done by photo, attach a map or a written description.
  • Please download the template and to indicate where you would like the plaque, and attach to this submission.
Declaration:
 

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City of Cockburn
Whadjuk Boodjar
9 Coleville Crescent,
Spearwood 6163

PO Box 1215, Bibra Lake DC,
Western Australia, 6965

Office opening hours:
8.30am to 4.30pm
Monday to Friday (excluding public holidays)

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Cockburn Nyungar moort Beeliar boodja-k kaadadjiny. Koora, yeyi, benang baalap nidja boodja-k kaaradjiny.
Ngalak kaditj boodjar kep wer kaadidjiny kalyakool yoodaniny, wer koora wer yeyi ngalak Birdiya koota-djinanginy.

The City of Cockburn acknowledges the Nyungar people of Beeliar Boodjar. Long ago, now and in the future they care for Country.
We acknowledge a continuing connection to Land, Waters and Culture and pay our respects to Elders, past and present.