Request for Inclusion on the Wall of the Fallen

Click here to download information packet.

To request inclusion for the Wall of the Fallen and the Survivor Fund, please click here.

Name of Deceased*
Date*
MM slash DD slash YYYY
Relationship to the Deceased*
Name of Person Requesting Funds*
Relative Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Driver's License Class*
Driver's License Number*
Driver's License State*
Driver's License Expiration*
Phone*
Email
Physical Address of the Deceased*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Date of Death*
MM slash DD slash YYYY
Years in Towing Industry*
Legal Name of the Deceased's Spouse
Name (s) of the Deceased's Children
Name of Company*
Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company Phone*
Company Email
Position of the Deceased With the Company*
Type of Vehicle*
Wrecker
Incident Details*
Date of Incident*
MM slash DD slash YYYY
Location of Incident*
Road Type*
Would you like to submit your information for the Survivor Fund?*
- Yes
- No
Name of the Person That Funds Will Be Distributed To
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Name of Person to Receive Funds*

*Distribution must be made to someone 18 or older.
List any other facts (if any) that you believe ITRHFM should be aware of
Documents Attached
Documents are not required in order to qualify
Death Certificate
Max. file size: 512 MB.
State Association Information
Max. file size: 512 MB.
Copy of Marriage Certificate
Max. file size: 512 MB.
Obituary
Max. file size: 512 MB.
Birth Certificates for Dependent Children
Max. file size: 512 MB.
Police Report of Incident
Max. file size: 512 MB.
Newspaper Article(s)
Max. file size: 512 MB.
Other
Max. file size: 512 MB.
Name of Police Department
Phone of Police Department
All pertinent documents should be attached to this form for submission. A copy of the police report should be submitted with this request if available. I certify that the above information is true and correct to the best of my knowledge at the time of submission. I understand that review by ITRHFM is confidential, and that its decision is final. I also understand that any award is discretionary, and that meeting the eligibility criteria does not guarantee an award. Should an award be made to me, I agree in advance to allow ITRHFM to list and publish the donation to me and my family.
Signature of the Submitter*
Date*
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Privacy Information: Submitting information is strictly voluntary. By doing so, you are giving the ITRHFM your permission to use the information for the intended purpose. If you do not want to give the ITRHFM Permission to use your information, simply do not provide it. However, not providing certain information may result in the ITRHFM ‘s inability to provide you with the services you desire.
© 2023 International Towing and Recovery Hall of Fame and Museum, Inc

Documents Attached