Northern Rockies Heritage Center
At Historic Fort Missoula

30 Fort Missoula Road
Missoula, MT 59804
Phone: (406) 728-3662
FAX: (406) 542-0601
Email: director@nrhc.org

APPLICATION for TREE MEMORIAL & PLAQUE

Today's Date:_________________________________________________________________

DEDICATEE NAME:______________________________________________________________

APPLICANT NAME:______________________________________________________________

ADDRESS:____________________________________________________________________

CITY, STATE, ZIP:______________________________________________________________

PHONE:_____________________________ EMAIL______________________________________

PLAQUE TYPE [check one]:

Exterior TREE PLAQUE, Coated Brass:
4" x 6" ($300)_____
8" x 10" ($500)_____
Interior FOYER PLAQUE, Brass:
3" x 5" ($150)_____
4" x 6" ($250)_____

PLAQUE TEXT REQUESTED
(applicant please clearly print or type text with line breaks below):

  1. text here________________________________________________________
  2. text here________________________________________________________
  3. text here________________________________________________________
  4. text here________________________________________________________

CAMPUS LOCATION DETERMINED:___________________________________________________

DETAILS/VARIANT TERMS:________________________________________________________

__________________________________________________________________________________

APPLICANT SPECIAL INSTRUCTIONS:_______________________________________________

__________________________________________________________________________________

APPLICANT NOTE: Please complete & return this form, with check payable to N.R.H.C.
Mail to: N.R.H.C., #30 Fort Missoula Rd., Missoula, MT 59804

PLEASE CHECK HERE______ if you wish a copy of this form returned to you for IRS Charitable Tax Deduction 501(c)(3) documentation.

PLEASE CHECK HERE______ and add $10 if you wish to receive a printed facsimile of your plaque, suitable for framing.