The Georgia Trust

PLACES IN PERIL NOMINATION FORM

Georgia’s Places in Peril 2013
Nomination Form

Do you know of a special irreplaceable historic building or site that is highly threatened by demolition, neglect, inappropriate development or other threats? If so, this is your opportunity to help save it. The Georgia Trust’s Places in Peril program seeks to identify and preserve historic sites threatened by demolition, neglect, lack of maintenance, inappropriate development or other threats. The 2013 Places in Peril list will be announced in October 2012.

Please complete this form and return it to The Georgia Trust marked “Places in Peril” at 1516 Peachtree Street, NW, Atlanta, GA 30309 or email to kryan@georgiatrust.org. Nominations can be e-mailed or mailed and must be postmarked or received by Monday, June 4, 2012. Be sure to submit 5 to 10 digital images (minimum size 4" x 6" jpg format at 300 dpi) on a CD. All materials submitted with the application are non-returnable and become property of The Georgia Trust. For further information, contact Kate Ryan at 404-885-7817 or kryan@georgiatrust.org.

PROPERTY INFORMATION

Name of Property: ________________________________________________________________

Address: ________________________________________________________________________

City / Zip Code / County: ___________________________________________________________

Date of Construction: __________ Current use of the building / site? _______________________

Ownership: □ Public □ Private

Historic Designation: □ National Historic Landmark □ National Register □ Unknown

*Please attach historic designation information if available. □ Georgia Register of Historic Places □ Locally Designated

□ None □ Unknown

NOMINATOR INFORMATION
Name: _________________________________________________________________________

Address: _______________________________________________________________________

Phone: ___________________________ Fax: _________________ E-mail: _________________

Other local groups or individuals involved -- non-profit organizations, “Friends of” groups, governmental entities, etc.:

Name: _________________________________________________________________________

Address: _______________________________________________________________________

Phone: ______________________Fax: _________________ E-mail: ______________________

On no more than two additional pages, please briefly answer the following questions (please type). All questions must be answered for the nomination to be considered.

1. Why is the building / site significant? Is it architecturally and/or historically significant? Does it contribute to a historic district? What makes it unique or different?

2. What is the history of the building / site? Please provide a brief historical summary.

3. Describe the nature of the threat to the site (demolition, neglect, lack of maintenance, inappropriate development, insensitive public policy, etc.) How imminent is the threat?

4. Who are the property owners and are they aware of the nomination? What is their attitude toward the property? Please provide their names and contact information.

5. Has any recent or past preservation activity occurred on behalf of the site? Please identify any entities, organizations and/or agencies that have a goal to save the site and that might be willing to work to implement a preservation plan for the site.

6. Is there any potential opposition to including this site on the list? If yes or maybe, provide the names, titles and contact information for those opposing the nomination and indicate reason for opposition (if known).

Nomination Check List (please check off and sign the form below).

_____ Completed nomination form and no more than 2 additional pages (if necessary)

_____ 5 to 10 digital images (4” x 6” jpg format at 300 dpi or larger) on CD

_____ Additional support material: historic designation information, etc. (as appropriate)

RELEASE AUTHORIZATION: This form must be signed in order for the nomination to be considered. The undersigned hereby gives The Georgia Trust a non-exclusive license to use, and allow others to use, in whole or part, all digital images, videos and other materials submitted to The Georgia Trust in connection with the Places in Peril nomination for publicity, audiovisual presentation, and/or promotion. The Georgia Trust is hereby given permission to make any editorial changes and/or additions to the materials referred to herein as it may deem necessary from third parties, including without limitation, models, creators, photographers, writers and producers, and that the undersigned will hold harmless and indemnify The Georgia Trust from and against any claim brought against The Georgia Trust from third parties that may arise out of the violation of this paragraph.

Release authorized by (signature) ___________________________________________________

Print or type name and title _________________________________________________________

Date_____________________________________________

For more information on the program or individual sites, contact Kate Ryan, 404-885-7817.

CONNECT WITH US

twitter

Site Map   |   Search