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(Rev. 10-90) NPS Form 10-900 OMB No. 1024-001 8 United States Department of the Interior National Park Service NATIONAL REGISTER OF HISTORIC PLACES REGISTRATION FORM This form is for use in nominating

The information submitted will be made part of the Register for submission to the national Register of Historic Places. 1. Property Name(s) the proposed designee is applying for designation of. 2. State, city, county, street, block, route, subdivision, building, building or parcel code number or code (if a federal code); 3. Property type (e.g., building, dwelling); 4. Geographic location from the nearest point (within 500 miles) the applicant has knowledge of, within the United States, or the applicant's current place of residence, or from the nearest post office located within the United States and can reliably communicate the applicant's address (all applicable post offices will be indicated); 5. Owner (individual, firm, association, partnership or corporation); 6. Type of use: recreational, historic, cultural, educational, environmental or other (if applicable); 7. Owner's name and address (if not a corporation, partnership, or individual); 8. Owner's contact information (name, address, cell phone and e-mail); 9. State or local or regional designation (United States, State, county, city, etc.) of historic period, type(s), location on the National Register or Federal Register, and any supplemental designations desired for this applicant or any other historical district. (See appendix A for additional information); 10. Designee's name and address (if not a corporation, partnership, or individual); 11. Designee's contact information (name, address, phone and e-mail); 12. History(s) to be included on historic district in question, including, but not limited to, building, land use, area or area unit; (If applicable, other information as listed in Appendix B or this form); 13. Architectural significance; 28 days prior to filing, the applicant shall contact the National Register of Historic Places at, Nominations for Historic Districts. Each proposed historic district shall be reviewed at least once by a national body at least one year prior to its listing on the National Register of Historic Places. For more information, see the Register of Historic Places' website at or contact the National Register of Historic Places at. The NPS Designee's designee must also submit the following items to the NPS National Historic Preservation Information Center, P.O.

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