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2. Town of Frederick Miners Memorial Wall Application for Engraving

   Please PRINT all known information on this form. Engraving is completed once a year. Applicants will receive a letter confirming that the Frederick Arts Commission has accepted the application, which must be received by August 1 st of each year. Proof of employment is required for placement on the wall (please attach a photo, story, paystub, or other documentation). There is a $200.00 fee for placement of a name on the wall. 

   For questions regarding this form, please contact the Town Clerk at (720) 382.5500. 

   MINER INFORMATION (Name to be engraved) 

4. First Name
5. Last Name
6. Middle Name or Intial
8. Address1

   Must meet residence criteria 

10. City
11. State
12. Zip
14. Mailing Address if different from above
16. Mine in which miner worked
18. Applicant Information (If submitting on Miners' behalf
20. First Name
21. Last Name
23. Phone #
25. Mailing Address
27. Applicant Comments for Consideration
29. I,
32. verify that the applicant is a former employee of a mine located in Colorado and have attached proof thereof to this application.
34. Authorized Signature
36. Date
38. Printed Name
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field