Heritage Commission Preservation Award Nomination

Project Name *

Location (for building, site or program/project. If no physical location, leave blank)

Municipality *

Category (see instructions) *

Description of Nomination *

If Nomination is an award-winner, please list the principal project participants (individuals and/or groups) that should be listed on Certificate (Please limit to total of 5): *

How many copies of the signed certificate would you need in total? *

Contact information

Contact Information for Primary Recipient of Award (will be noted as primary recipient and will be used as main contact to notify other participants):

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Nomination submitted by: