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<br />City of Pleasanton <br />Memorial Bench Donation Application <br />(TO BE COMPLETED BY APPLICANT, PLEASE PRINT LEGIBLY) <br />APPLICANT INFORMATION: <br />Name of Donor <br />Address of Donor <br />Home Phone Cell Phone <br />Email Address <br />DONATION INFORMATION: <br />Location of Donation <br />Alternate Location <br />Wording on Memorial Acknowledgment <br />Approved Location <br />Donation Payment Method □Cash □Check □Credit/Debit Card <br />MEMORIAL BENCH DONATION FEE SCHEDULE <br />DONATION TYPE INSTALLATION COST <br />Park Bench $5,000.00 <br />I HAVE READ AND AGREED TO THE TERMS OF THE MEMORIAL AND DONATION <br />POLICY <br />Requested By Date <br />(TO BE COMPLETED BY CITY STAFF) <br />Reviewed and Approved by: <br />Parks Department Date <br />Library and Recreation Department Date <br />Recreation Office: <br />400 Old Bernal Ave. Pleasanton, CA 94566 <br />(925) 931-5340 <br />recreation@cityofpleasantonca.gov <br />www.cityofpleasantonca.gov/ <br />Appendix A <br />Page 94 of 318