Order A Certificate

Do you know someone who will be celebrating a Birthday, Graduation, Anniversary, or Retirement in the near future? If so, you may request a celebratory certificate from Jack MacLaren, Member of Provincial Parliament for Carleton-Mississippi Mills, to recognize their special occasion.

*This service is only available for constituents of Carleton-Mississippi Mills. If you are not a constituent of this riding you may contact your own Member of Provincial Parliament for this service.

REQUESTOR INFORMATION

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Phone Number*:

E-mail*:

CELEBRANT INFORMATION

Age of Celebrant*:

Date of Birthday*:

Date of Celebration:

If no celebration date is provided, the certificate will be sent according to the birthday date.

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Delivery Instructions
CelebrantRequestor

REQUESTOR INFORMATION

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Phone Number*:

E-mail*:

GRADUATE INFORMATION

Graduation:

School Name*:

Date of Graduation*:

*Date of Celebration*:

If no celebration date is provided, the certificate will be sent according to the birth date.

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Delivery Instructions
GraduateRequestor

REQUESTOR INFORMATION

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Phone Number*:

E-mail*:

CELEBRANTS INFORMATION

Years Married*:

Date of Anniversary:*

Date of Celebration:

If no celebration date is provided, the certificate will be sent according to the anniversary date.

First Name*:

Last Name*:

First Name*:

Last Name*:

Mailing Address*:

Town/City*:

Province*:

Postal Code*:

Delivery Instructions
CelebrantsRequestor

REQUESTOR INFORMATION

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Phone Number*:

E-mail*:

RETIREE INFORMATION

Entity Name*:

Entity Type*:

Position*:

Years of Service*:

Date of Retirement*:

Date of Celebration:

If no celebration date is provided, the certificate will be sent according to the retirement date.

First Name*:

Last Name*:

Address*:

Town/City*:

Province*:

Postal Code*:

Delivery Instructions
RetireeRequestor