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*

Address

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

Incident or Accident Report

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

Death Certificate or Equivalent Documentation

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

Other Supporting Material (e.g. photographs, news articles etc)

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*

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Lost at Sea Memorial Application

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