City Naming Registry Application Form

Applicant Name:

Phone:

Email:

Address:

Postal Code:

Name to be Considered: (How it appears is how it will be recorded)

Applicant’s Relationship to the Individual/Family:

Is the application for:

An Individual

A Family Name

Is the Name for a Specific Property in the City?

Yes

No

If yes, include legal description and how the area of land and name are related:

The proposed name being submitted for consideration should: (Select all that apply)

Recognize exceptional community service or public contribution to honour those individuals who have demonstrated outstanding service, leadership, or philanthropy, resulting in a lasting positive impact on the community;

Reflect the City’s history of Indigenous and settler cultures and traditions, as well as acknowledge those individuals who have played a prominent role in developing and shaping the City;

Celebrate the City’s heritage, community spirit and diversity;

Recognize a legacy of leadership, public service or public office for those exemplary individuals with outstanding and exceptional contributions to the City;

Commemorate acts of bravery or sacrifice;

Recognize individuals with significant contributions to the planning, funding, construction, or advocacy for community buildings, events or services;

Recognize individuals or families whose outstanding contributions or excellence brings recognition to the City of Fort Saskatchewan, the Province of Alberta or the Country of Canada; or

Pay tribute to individuals who have made outstanding contributions to the advancement of community programs and activities, civic pride, or social justice and equity.

Provide background on the broad range of public services and/or community activities the individual/family was involved with, length of service, and how significant their contribution was to the City:

Applications require consent from the individual/family to be considered for placement on the Name Registry and that the information provided is accurate. (Please note that consent is not required where the individual named for consideration has been deceased for 25 years or more).

I (full name),

hereby certify that:

I am the individual named for consideration; or

I am a family member authorized to act on behalf of the individual or family named for consideration;

and consent to consideration for placement on the City Naming Registry and that the information provided is accurate.

Signature:

Clear

Date:

Phone:

Email:

Other information to support the application:

In order for your proposed City Naming application to be deemed complete, please submit the following information along with your completed application.

Biography of individual or family containing information that is publicly verifiable

Supporting public documents such as photographs, articles, awards, citations, etc.

Further information can be found in the City Naming Policy GOV-002-C at fortsask.ca/policies.

Supporting document(s) upload:

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Allowed extensions pdf, doc, docx, jpg, jpeg, png

Office Use Only:

Date: Received:

File Number:

Application Meets Criteria:

Council Approval Given:

Date added to Naming Registry:

The personal information collected on this application is in accordance with Section 33(c) of the Freedom of Information and Protection of Privacy Act (FOIP), and will be used in relation to the City’s Naming Registry. Questions about the collection and use of this information can be directed to the City`s FOIP Coordinator at 780-992-6200.

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City Naming Registry Application Form

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