Nomination Form
Completion of this form starts the ball rolling. It doesn't guarantee your nomination will be placed of the Raleigh County Register of Historic Places, but it will help the commission make such a determination and serve as a permanent record. Insert an asterisk after each answer at which you're only guessing.
 
Contact Information
Your Name:
Address:

Not for Publication (Check Box):

City/Town:

WV ZIP Code:

Home Phone:
Work Phone:
Fax:
E-mail:
Name of Place
Historic:
Common:

Location
Physical Address:
Not for Publication (Check Box):
City/Town/Vicinity Of:
Zip Code:
Deed Book/No.:
County Map No.:

Owner
Name:
Not for Publication (Check Box):
City/Town/Vicinity Of:
Zip Code:
Condition (Select One): Excellent
Good
Fair
Deteriorated
Ruins
Unexposed
Period of Significance (Select One): Prehistoric
1700-1799
1800-1899
1900-Present
Significance (Check Box): Agriculture
Commerce
Residence
Religious
Industry
Education
Entertainment
Transportation
Government
Military
Scientific
Park/Museum
Other
Date of Construction:
Builder/Architect:
Present Use (Check Box): Agriculture
Commerce
Residence
Religious
Industry
Education
Entertainment
Transportation
Government
Military
Scientific
Park/Museum
Other

Statement of Significance

Let us know what's important about  this historic place.:





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