African American Heritage Trail Nomination Form

Does your nomination have a physical site that can be visited?

Yes, there is a physical location

No, there is no physical location

Site Name:

Site Address

Name of Individual or Group Associated with Site

Name of Property/Site Owner

Permission of Property/Site Owner to Include the Site:

Yes

Site Hours of Operation

Site Phone Number

Site Website

Significance of Site

Story Name

Approximate Location

Name of Individual or Group Associated with Story

Significance of Story

Narrative: Please provide a narrative of the historical and/or cultural contributions/significance made by the individual or site nominated.

Historic Documentation: Please provide citations to historical documents, news clippings, photographs, or other written records to support your factual information.

One file only.
5 MB limit.
Allowed types: jpg, pdf, doc, docx.

Your Name

Your Affiliation (if any)

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Date of Nomination