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 NPS Form 10-900
OMB No. 1024-0018
(Rev. 8-86)
United States Department of the interior
National Park Service
National Register of Historic Places
Registration Form
This form is for use in nominating or requesting determinations of eligibility for individual properties or districts. Sea instructions in Guidelines
for Completing National Register Forms (National Register Bulletin 16). Complete each item by marking "x" in the appropriate box or by entering
the requested information. If an item does not apply to the property being documented, enter "N/A" for "not applicable." For functions, styles, materials,
and areas of significance, enter only the categories and subcategories listed in the instructions. For additional space use continuation sheets
(Form 10-900a). Type all entries.
1. Name of Property
historic name
other names/site number
2. Location
Iu
street & number
not for publication
u
vicinity
city, town
state
code
county
code
zip code
3. Classification
Ownership of Property
Category of Property
Number of Resources within Property
u
u
private
building(s)
Contributing
Noncontributing
u
u
public-local
district
buildings
u
u
public-State
site
sites
u
u
public-Federal
structure
structures
u
object
objects
Total
Name of related multiple property listing:
Number of contributing resources previously
listed in the National Register
4. State/Federal Agency Certification
As the designated authority under the National Historic Preservation Act of 1966, as amended, I hereby certify that this
u
u
request for determination of eligibility meets the documentation standards for registering properties in the
nomination
National Register of Historic Places and meets the procedural and professional requirements set forth in 36 CFR Part 60,
u
u
u
meets
does not meet the National Register criteria.
See continuation sheet.
In my opinion, the property
Signature of certifying official
Date
State or Federal agency and bureau
u
u
u
meets
does not meet the National Register criteria.
See continuation sheet.
In my opinion, the property
Signature of commenting or other official
Date
State or Federal agency and bureau
5. National Park Service Certification
I, hereby, certify that this property is:
u
entered in the National Register.
u
See continuation sheet.
u
etermined eligible for the National
u
See continuation sheet.
Register.
u
etermined not eligible for the
National Register.
u
removed from the National Register.
u
other, (explain:).
Signature of the Keeper
Date of Action
D-2
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