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2. Adopt-A-Bench/Table Donation Form
4. Donor Information
6. First Name*
7. Last Name*
9. Street*
10. City, State, Zip Code*
12. Phone Number*
13. E-Mail Address*
15. Bench or Table Information
17. Bench or Picnic Table*

    1. Bench
    2. Picnic Table
18. Location Requested*
    Please describe as specifically as possible.
20. 8"x2" Cast Bronze Plaque Text*
    Please use exact wording, all uppercase. Up to 3 lines and maximum of 20 characters/spaces per line. Refrain from using profane, obscene or hostile words. While religious and political organizations may be recognized, no religious or political messages are allowed.
22. Special Instructions
24. Payment and Installation Details
    - Must include payment of $1,100 for each bench or picnic table.
    - Bench purchase and installation will be handled by Leb Rec to ensure uniformity.
    - Duration of time between receiving order and payment, and installation is about 2 months.
    - Memorial plaque will remain attached for the life of the bench or table.
26. Payment Options*

    1. Please e-mail me a link to pay via credit card.
    2. I will make a check payable to City of Lebanon and mail it to Lebanon Recreation, Arts and Parks Department, 51 North Park St., Lebanon, NH 03766.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field