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VILLAGE OF ROMEOVILLE COMMEMORATIVE PROGRAM

Park Bench Application Form

Created February 26, 2021
Description:

The Village of Romeoville is offering a unique opportunity for residents to honor a current or former community member through the Commemoration Program. The program is utilized as a way to recognize individuals that have made a significant contribution or impact on the community.
APPLICATION PROCESS

The nominator should complete and submit the form. The Committee will then make a recommendation to the Village Board. Each application must meet the criteria as set forth, although meeting all criteria does not ensure naming rights. The Committee has the right to deny any application for any reason at any time or waive requirements as set forth. Applications with names or nick names that endorse or advocate religion or specific religious beliefs, have obscene connotations, or demean or attempt to intimidate any group based on the group’s race, ethnicity, age, gender, disability, or sexual orientation will be denied.
Fee for park bench can be submitted via check payable to the Village of Romeoville. Mail to: Village of Romeoville, 1050 W. Romeo Rd, Romeoville, IL 60446 Attn: Dawn Caldwell.
QUALIFICATIONS

To qualify, the honoree must be a former or current Romeoville resident and successfully passed a background check.
SELECTION

The completed form will be reviewed to determine if all criteria has been met. If all criteria has been met, the honoree's application will be forwarded to the Commemorative Program Committee which consists of an elected official, the Village Manager, a Village of Romeoville employee, a non-profit representative and a Romeoville resident.
NOTIFICATION

If honoree is selected, the Committee will inform the nominator and the honoree via letter.
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NOMINATOR INFORMATION

Name:
Email Address:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
Honoree Name:
Relationship to Honoree:
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HONOREE INFORMATION

Name:
Email Address:
Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Cell Phone:
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QUALIFICATIONS

Is honoree a current Romeoville resident?
1. Yes
2. No
If yes, please indicate the year the honoree moved to Romeoville:
Is honoree a former Romeoville resident?
1. Yes
2. No
If yes, please indicate the years that the honoree lived in Romeoville:
Please indicate the last four digits of driver's license number in order to complete the background check:
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PARK BENCH PERSONALIZATION

Commemorations can be made by purchasing a park bench. Park Benches are $1,500 and includes the bench, delivery, installation, a commemorative plaque, and maintenance. Park benches are 6' long and made of composition-recycled material with an oak look. The bench will be located in a Village park or other designated area within the community. The Village, taking into consideration the nominator’s requests, will select the final location.
A commemorative plaque comes with park benches. Please select from the following plaque options:
1. In Loving Memory of
2. In Honor of
3. In Celebration of
4. Other
If other, please consider the below wording for consideration on the plaque:
Name of person to be engraved on plaque:
Park Bench Location Preference:
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CONDITIONS

Checking the box indicates that I certify that all statements and information furnished in this form are true, complete and correct to the best of my knowledge, and are made in good faith. I understand that statements or information furnished on this form are subject to verification and I agree to furnish supporting documents or information when requested.
1. I have read and agree to the conditions.
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OFFICE USE ONLY

Date Approved:
Location:
Date Denied:
Fee:
Date Payment Received:
Reason for Denial:
Signature:
The completed form will be submitted via email for review and approval. For additional information, contact the Village of Romeoville at 815-886-7200.

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Commemorative Program - Park Bench Application Form

Steps

Step One

NOMINATOR INFORMATION

HONOREE INFORMATION

QUALIFICATIONS

PARK BENCH PERSONALIZATION

CONDITIONS

OFFICE USE ONLY

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