MCHS sites

Manitowoc County Historical Society Historic Preservation Award Nomination Form

(Please print, then complete and mail to MCHS, 1701 Michigan Ave, Manitowoc, WI 54220)

Nominee: __________________________________________________________

(Organization or Individual Nominated)

Address: __________________________________________________________

Street City Zip ______________________________________________________

Telephone: _______________________________________________________

Category in which Project, Property or Achievement is nominated:

¨ Adaptive Reuse	¨ Preservation Service
¨ Restoration	¨ Bob Fay Lifetime Achievement

Name of Nominated Project, Property, or Achievement:

_____________________________________________________________________

Address of Historic Property: ___________________________________________________________________________

*Nominated by: ________________________________________________________________________________________

(Name)

__________________________________________________________________________________________________________

Street City Zip

____________________________________________________________________________________________________________

Telephone (work) (home)

* Documents will be returned to this person.

1. Describe the Historic Preservation Project or Achievement of Nominee. (You may use additional sheets)

2. Documentation submitted. To be eligible for an award you must submit supporting documentation for the nominated project, property or achievement. List documents: these can include but are not limited to: newspaper clippings, photos, slides, brochures, blueprints etc. Attach or enclose them with this form.

3. Signature ___________________________ Date _________________________

Nomination form and supporting documents must be received by November 30th, 2006.

Mail to: Manitowoc County Historical Society | Attn: Historic Preservation Committee

1701 Michigan Avenue | Manitowoc, WI 54220