Blue Plaque application

Name of the subject of the Blue Plaque

Date of birth and/or death (if applicable)

Date of birth

Date of death

Reasons you wish this person/place/event to be considered for a Blue Plaque

Do you have funding in place for the Blue Plaque?

Yes

Cost: Approximately £1000

Proposed wording for the Blue Plaque

Maximum 28 words

Your contact details

Name

Company

Phone

Address

Postcode

I agree to the above information to be submitted to the Cultural Committee for consideration and will abide by the Blue Plaque Guidelines should the application be successful.

Signed

Sign above

Name

Date