Preservation Worcester’s 2008 Most
Endangered Structures Nomination Form
(Please complete to the best of your knowledge)
SITE INFORMATION
Property Name:
__________________________________________________________________
Property Address:
________________________________________________________________
City, State, Zip Code: ____________________________________ Telephone:
______________
PROPERTY OWNER
INFORMATION
Name:
_________________________________________________________________________
Address:
_______________________________________________________________________
City, State, Zip Code:
____________________________________
Telephone: ______________
NOMINATOR INFORMATION (names will be kept confidential)
Name:
_________________________________________________________________________
Affiliation/Relation to nominated property: ____________________________________________
Address:
_______________________________________________________________________
City, State, Zip Code:
_____________________________________________________________
Telephone: (Day)
________________ (Evening) ________________ (Fax)
________________
Email address:
___________________________________________________________________
DESCRIBE THE PROPERTY,
INCLUDING ANY BACK TAXES DUE AND/OR LEINS ON THE PROPERTY IF
KNOWN, AND ANY IMMEDIATE
THREATS.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
DO
YOU HAVE ANY HISTORICAL INFORMATION ON THE PROPERTY?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Nominations
due by January 15, 2008
Please mail, email or deliver the completed form to
Preservation Worcester,
or
info@preservationworcester.org. Please include photographs, digital
preferred, on a CD or via email.