THE ROYAL CANADIAN ARMY SERVICE CORPS ASSOCIATION Application to Scatter Ashes ~ Canadian Forces Base Borden Applicant 1. Name: _____________________________________________________________________ 2. Address: ____________________________________________________________________                  _____________________________________________________________________ 3. Telephone [include area code]: _________________________________________ Deceased 4. Name of Deceased: ________________________________ Religion: ___________________________ 5. Rank on Retirement: ______________________________ Service Number: ______________________ 6. Regimental Affiliation: ________________________________________________________________ 7. Date of Enrolment (day/month/year): _____________ Date of Retirement (day/month/year): ____________ 8. Date of Death: (day/month/year): _____________________________ 9. Decorations and Medals: ___________________________________________________________________ Ceremony of Scattering 10. Preferred date for scattering ashes or unspecified (day/month/year): ______________________ 11. Ashes be accompanied to Borden by: ______________________________________________ 12. Is there a requirement for a Chaplain:   Yes   No   [circle one] 13. Preferred language for Chaplain Service:   English   Francais [circle one] 14. Any other pertinent information: ______________________________________________________________ __________________________________________________________________________________________ Memorial It is desired that that the name of the deceased be engraved on a tablet in Waggoners Park, and that an engraved brass plate (1/2 inches x 4 inches) bearing the name of the deceased be placed on the wall of the Memorial chapel of the Base Borden Military Museum. Enclosed with this application is a cheque or money order in the amount of $210.00 (payable to the Base Borden Military Museum) for this purpose. _______________________________________ Signature

Submit application to: Director; Base Borden Military Museum; Canadian Forces Base Borden; 18 Waterloo Road East; P.O. Box 1000 Station Main; Borden, ON   L0M 1C0 ___________________ Upon completion keep a copy of this application for your records