Certificate Request Form

Fill out the form below to request a certificate for a special occasion.
Type of Occasion*
- Milestone Birthday
- Retirement
- Wedding Anniversary
Date of Occasion*
MM slash DD slash YYYY
Name of Recipient(s)*
First Last
Mailing Address of Recipient
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Celebration Date*
MM slash DD slash YYYY
Number of Years*
Name(s) as it should appear on the certificate (with Rank if applicable)*
Delivery Options*
- I will pick it up at City Hall
- Please mail it to the recipient
- Please mail it to the requester
Requester name*
First Last
Requester Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Requester Telephone Number
Requester Email Address*
If you require further assistance, please do not hesitate to contact us at 613-392-2841, Ext. 4433 Personal Information contained on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of responding to your request. Questions about this collection should be directed to the Freedom of Information and Privacy Coordinator/City Clerk for the City of Quinte West, 7 Creswell Drive, PO Box 490, Trenton, ON K8V 5R6 or at 613-392-2841.
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