Name of Applicant:

Email:

Applicant's Address:

Contact Number:

Name of property and location/address

Name of property owner, address and contact information

Does the owner support the nomination? Yes No

Describe the importance of the building in the community

Is the building on the National Register of Historic Places?
Yes
No
I don’t know

What was the condition of the property before preservation?

Describe the project rehabilitation process:

How would the selection of this property as an award recipient benefit the district or community around it in the future?

Please include 3 color pictures of the property: front, rear, inside and outside photographs. Pictures may be good quality digital images/scans.
Pic 1:
Pic 2:
Pic 3:

Include a brief history of the building, list the built date and all major change. Document should be in Microsoft Word (.doc) format.