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2008 PLACES IN
PERIL NOMINATION FORM
Georgia’s Places in
Peril 2008
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 2008
Places in Peril list will be announced in
November 2007.
Please complete this form and
return it to The Georgia Trust marked “Places in Peril” at
the address above. Nominations can be e-mailed or
mailed and must be postmarked or received by Friday, June
8, 2007. Be sure to submit 5 to 10 digital images (3”
x 5” 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 Preservation Manager
(404-885-7817 or
preservationmanager@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
*Please attach
historic □ Georgia Register of Historic
Places □ Locally Designated
designation
information □
None □
Unknown
if
available.
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 (3” x 5” jpg format at 300 dpi) 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
Preservation Manager, 404-885-7817
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