KWAZULU NATALMIDLANDS DISTRICT DUGOUT

APPLICATION FOR A MOTH PLAQUE TO BE AFFIXED ON THE

REMEMBRANCE WALL AT MOUNT MEMORY SHRINE

* See notes on reverse side of application*

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SECTION 1

a)Full names of deceased Moth: ………………………………………………………………………

b)Last residential address: …………………………………………………………………………......

c)Date of Sunset Call (death): …………………………………………………………………………...

d)Was a member of ………………………………………Shellhole City/Town: …………………

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SECTION 2

a)Full names of person making application: ……………………………………………………………

b)Postal address: ……………..……………………………………………………………………......

c)Relationship of deceased: …..………………………………………………………………………...

d)Shellhole Executives : If you wish to have a Shellhole “group” plaque affixed to the Remembrance Wall please state the date of your Shellhole Charter

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SECTION 3

This section to be completed by the Old Bill of the last Shellhole where the deceased Moth was a member

a)I certify that the late Moth …..………………………………………………………………………

was a member of ……………………………………………………….Shellhole

b)Address of Shellhole: ……………………………………….……………………………………......

SIGNED: ………………………………..……DATE: ………………….……………..

OLD BILL

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SECTION 4

a)I the undersigned applicant named in Section 2 above, hereby accept that the standard plaque utilized by the Kwazulu Natal Midlands District Dugout will be affixed to the Remembrance Wall at MountMemory and I will have no recourse against the dugout for any damage sustained the plaque after affixing to the wall.

b)I attach my remittance for R ………………..

Signed ………………………………………..DATE: ………………….……………...

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FOR OFFICIAL USE ONLY

PLAQUE IN NAME OF MOTH: ......

Affixed on Brick No.: …………....….. In Column: ……………………. Date Affixed: ………….……………

Signed by: ………………………………………………………………….and entered in register

NOTES

a)The plaque is 200 mm X 60 mm in size and bears the M.O.T.H. emblem on the left hand side of the plaque. The plaque is made of weather able acrylic plastic in silver with black lettering.

b)All plaques will be of standard wording as indicated on the sample below

200 mm

60 mm

c)The fee for the plaque is R 200.00 (inclusive of VAT) and is payable on application (such fee is subject to change without notification)

d)Please return completed application form and remittance to:

Ultra Badge & Metal (Pty) Ltd

(Mount Memory plaques)

PO Box 1651

ESTCOURT

3310

e)Cheques/postal orders to be made out to: ULTRA BADGE & METAL (PTY) LTD

f)Should a Shellhole apply for a plaque to be affixed, the Shellhole to complete Section 2 of the application

g)Shellhole Group plaques: The format will be as follows

200 mm

60 mm