pdf iconPrint
UCLA Procedure 113.0 : Attachment A

Proposal Form for Memorial and Honorific Objects

 

UCLA Policy 113, Memorial and Honorific Objects, describes under what circumstances a proposal for a Memorial or Honorific Object in honor or memory of an individual, group, or event may be considered for approval. It is recommended that this Policy be read before submitting a proposal. This form may be used or equivalent document that contains the required information for preparing a proposal. If a gift is involved, please contact External Affairs.
 


Date: __________________________
 
Proposer (Name):_______________________________
Department: ___________________________________
                                      (if applicable)
Representing:____________________________________________________________________________________
                                                                                   (if applicable)
Email: _____________________________________
Phone: ________________________________

 

Type of Memorial Object  (please check):
 
__ Bench     __ Fountain     __ Monument     __ Plaque     __ Sculpture     __ Other (please specify)
 
_______________________________________________________________________________________________
 
Subject of Memorial Object:__________________________________________________________________
 
Description of Subject (attach additional pages as needed):___________________________________________

Proposed verbiage on Memorial Object:____________________________________________________________
 
_______________________________________________________________________________________________
 
Suggested location of Memorial Object and reason. 
 
________________________________________________________________________________________________
 
 
Source of funding for Memorial Object design and manufacture, installation and maintenance costs:
 
________________________________________________________________________________________________
 
________________________________________________________________________________________________
 
Is a dedication ceremony planned? If yes, describe including desired date and source of funding:
 
________________________________________________________________________________________________
 
________________________________________________________________________________________________


Submit the completed form and any additional pages to:

Office of the Vice Chancellor & Chief Financial Officer
405 Hilgard Avenue
Murphy Hall 2147
Los Angeles, CA 90095
Attn: Memorial and Honorific Object
s