Commemorative Plaque application form

IMPORTANT: please read about the criteria for a plaque before completing this form.

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Step 1 of 5

Applicant's Name

First

Last

Organisation (if applicable)

If you are making the application on behalf of an organisation please tell us the name of the organisation.

Mobile number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Full address of the building, including the Eircode

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name of the owner of the building

Does the owner live at the same address as where the plaque is to go?

Full address of the owner of the building

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Please provide a copy of consent from the owner of the building for the erection of the plaque.

Click or drag a file to this area to upload.

Please note, the application will not be considered if the owner of the premises has not given consent to the erection of the plaque.