Lost at Sea Memorial Application

Please read the Shire of Esperance Council Policy prior to making a submission.

If you have any questions, feel free to call the Shire Asset Team on (08) 9071 0666.

Name*

Street Address:*

City:*

State:*

Post Code:*

Country:*

Phone Number*

Email Address*

Information About the Individual Lost at Sea

Full Name*

Date of Birth*

Date of Loss*

Connection to Local Area*

Brief description of the loss*

Supporting Documentation

Required Documentation*

Incident or Accident ReportDeath Certificate or Equivalent DocumentationOther Supporting Materials

Max File Size: 10.00 MB
Allowed File Types: .jpeg, .jpg, .pdf, .png

Max File Size: 10.00 MB
Allowed File Types: .gif, .jpeg, .jpg, .mov, .mp3, .mp4, .mpeg, .mpg, .pdf, .png

Agreement and Consent*

I, the undersigned, confirm that the information provided is accurate to the best of my knowledge and that I consent to the inclusion of the name and/or image on the memorial. I understand that the format and grammar of my submission might change.

Signature*

Date of Signature*

Collection Notice

By submitting this form, you acknowledge that the Shire of Esperance collects and uses personal information for the purpose of administering its services and functions such as maintaining accurate records, and meeting legal, reporting, and governance obligations. For more information about how we collect, use, and store personal information, please refer to our Privacy Policy.

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Lost at Sea Memorial Application

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