MEMORIAL BOARD FORM

DONOR INFORMATION (individual ordering the plaque)
First name   Province
Last name   Postal Code
Address   Email
City   Phone
 
DEDICATION PLAQUE
I would like to dedicate plaque/s at $540 per name/plaque.

To purchase more than 2 plaques or to sponsor a board dedication
please email us at [email protected] or call the office at 613.843.7770

Please inscribe the following name on the memorial tablet: 
PLAQUE #1   PLAQUE #2
Last Name   Last Name
First Name   First Name
Hebrew Name   Hebrew Name
Father's Hebrew Name   Father's Hebrew Name
Date of Passing   Date of Passing
After dark? Yes No   After dark? Yes No
 
PAYMENT DETAILS
(Alternatively you may print this form and mail with a cheque or multiple post-dated cheques to Ottawa Torah Centre 111 Lamplighters Drive Ottawa, ON K2J 0C2)
Paying by Credit Card Check
Payments can be made in one lump sum or multiple installments (if more time is needed, please call the office)
Name on card   Amount to be charged
Card Number   Card Type
Exp. Date   CVV Code 3 digits on back of card

I would like to have the following payment schedule, please charge my credit card accordingly:

My post dated cheques payable to OTC are in the mail.