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2. Applicant Details
4. First Name
5. Last Name
7. Name
8. Email Address
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. Fax Number
19. Recipient Details
21. First Name
22. Last Name
24. Milestone Details
26. Date of Milestone
    Date of Milestone
28. Date Certificate is required
    Date Certificate is required
30. Nature of Milestone
    eg. 25th Wedding Anniversary, 75th Birthday
32. How would you like the certificate to be sent to you?
    -- Select One --Pick-up at City HallBy mailEmail
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field