Name(s) of deceased

First name

Last name

Your details

Your name

Your title

Your address

Your postcode

Your telephone

Your email

Plaque image

If you would like the memorial plaque to feature your loved one's photograph or bespoke image, you can upload it. This will cost an additional £150.

Alternatively, you can also choose a design to be printed onto the plaque.

If you do not want the plaque to have an image, please select 'no image'.

Please choose lettering colour

GoldSilver

Plaque message

The name uses a larger typeface than the rest of the inscription and cannot exceed more than 12 letters. Please remember to use spaces in your inscription.

We recommend you use no more than 2 lines for your loved one’s name. If you need to use line 3 as additional space for your loved one’s name, then you cannot use line 6 for the rest of your inscription.

Declaration

I agree that Bereavement Services can provide and install a granite plaque on the Barbican Memorial. I give permission for inscription I have written to be used on the plaque.

I understand that the right to display the plaque lasts for 10 years from the date I sign this form.

If I want to keep the plaque on the Barbican, I must apply to renew the lease and pay the renewal fee before it expires.

If I do not renew the lease, I understand that I can come to collect the plaque, or it will be disposed of.