Download:
pdf |
pdfNPS Form 10-934 (Rev. 02/2022)
National Park Service
OMB Control No. 1024-0276
Expiration Date ##/##/####
NATIONAL HISTORIC LANDMARK NOMINATION
1. NAME AND LOCATION OF THE PROPERTY
Historic Name: Enter Historic Name
Other names / site number: Enter Site Number
Street and number: Enter Street number
City or town: Enter City/Town
State: Enter State
County: Enter County
2. SIGNIFICANCE DATA
NHL Criteria: Enter NHL Criteria
NHL Criteria Exceptions: Enter NHL Criteria Exception
NHL Theme(s): Enter NHL Theme
Period(s) of Significance: Enter Periods of significance
Significant Person(s) (only Criterion 2): Enter Significant Persons
Cultural Affiliation (only Criterion 6): Enter Cultural Affiliation
Designer/Creator/Architect/Builder: Enter Name of Designer/Builder/Creator/Architect
Historic Contexts: Enter Historical Context
3. WITHHOLDING SENSITIVE INFORMATION
Does this nomination contain sensitive information that should be withheld under Section 304 of the National
Historic Preservation Act?
☐Yes
☐ No
Page 1 of 5
NPS Form 10-934 (Rev. 02/2022)
National Park Service
OMB Control No. 1024-0276
Expiration Date ##/##/####
NATIONAL HISTORIC LANDMARK NOMINATION
4. GEOGRAPHICAL DATA
A. Acreage of Property: Enter Acreage of Property
B. Use either Latitude/Longitude Coordinates or the UTM system:
a. Latitude/Longitude Coordinates:
Datum if other than WGS84 (enter coordinates to 6 decimal places):
Latitude: Enter Latitude
Longitude: Enter Longitute
OR
b. UTM References: Zone Enter Zone
Easting Enter Easting Northing Enter Northing
C. Verbal Boundary Description: Enter description of boundary of the Property
D. Boundary Justification: Enter justification for the boundary of Property
5. SIGNIFICANCE STATEMENT AND DISCUSSION
INTRODUCTION: SUMMARY STATEMENT OF SIGNIFICANCE
Enter Summary
PROVIDE RELEVANT PROPERTY SPECIFIC HISTORY, HISTORICAL CONTEXT, AND THEMES.
JUSTIFY CRITERIA, EXCEPTIONS, AND PERIODS OF SIGNIFICANCE LISTED IN SECTION 2
Enter details
Page 2 of 5
NPS Form 10-934 (Rev. 02/2022)
National Park Service
OMB Control No. 1024-0276
Expiration Date ##/##/####
Name of Property
6. PROPERTY DESCRIPTION AND STATEMENT OF INTEGRITY
Ownership of Property
Category of Property
Private: Enter details
Building(s): Enter details
Public-Local: Enter details
District: Enter details
Public-State: Enter details
Site: Enter details
Public-Federal: Enter details
Structure: Enter details
Object: Enter details
Number of Resources within Boundary of Property:
Contributing
Noncontributing
Buildings: Enter details
Buildings: Enter details
Sites: Enter details
Sites: Enter details
Structures: Enter details
Structures: Enter details
Objects: Enter details
Objects: Enter details
Total: Enter details
Total: Enter details
PROVIDE PRESENT AND PAST PHYSICAL DESCRIPTIONS OF PROPERTY
(Please see specific guidance for type of resource[s] being nominated)
Enter details
7. BIBLIOGRAPHICAL REFERENCES AND OTHER DOCUMENTATION
NPS Form 10-934 (Rev. 02/2022)
National Park Service
OMB Control No. 1024-0276
Expiration Date ##/##/####
NATIONAL HISTORIC LANDMARK NOMINATION
Previous documentation on file (NPS):
Previously Listed in the National Register (fill in 1 through 6 below)
☐ Not previously listed in the National Register (fill in only 4, 5, and 6 below)
1.
NR #: Enter NR #
2.
Date of listing: Enter date of listing
3.
Level of significance: Enter level of significance
4.
Applicable National Register Criteria:
A☐ B☐ C☐ D☐
5.
Criteria Considerations (Exceptions):
A☐ B☐ C☐ D☐ E☐ F☐ G☐
6.
Areas of Significance:
☐
Previously Determined Eligible for the National
Register:
☐
Date of determination: Enter date
Enter details
Designated a National Historic Landmark: Enter
Date of designation: Enter date
details
☐
Recorded by Historic American Buildings Survey:
HABS No. Enter HABS no.
Enter details
☐
Recorded by Historic American Engineering Record:
HAER No. Enter HAER no.
Enter details
☐
Recorded by Historic American Landscapes Survey:
HALS No. Enter HALS no.
Enter details
Page 4 of 5
NPS Form 10-934 (Rev. 02/2022)
National Park Service
OMB Control No. 1024-0276
Expiration Date ##/##/####
Name of Property
Location of additional data:
State Historic Preservation Office: Enter details
Other State Agency: Enter details
Federal Agency: Enter details
Local Government: Enter details
University: Enter details
Other (Specify Repository): Enter details
8. FORM PREPARED BY:
Name/Title: Enter Name/title
Address: Enter Address Line 1
Enter Address line 2
Enter City Enter State Enter Zip Code
Telephone: Enter telephone No.
E-mail: Enter Email
Date: Enter Date
Edited by:
National Park Service
National Historic Landmarks Program
1849 C St. NW (2280)
Washington, DC 20240
Telephone:
(202) 354- Enter last 4 digits
NOTICES
Privacy Act Statement
Authority: This information is authorized by the Historic Sites Act of 1935 (16 U.S.C. 461-467) and 36 CFR part 65.
Purposes and Uses: This information is being collected to determine the eligibility of properties for nominations as a National Historic
Landmark.
Effects of Nondisclosure: Voluntary, however, response to this request is required to obtain a benefit in accordance with the Historic Sites
Act of 1935 (16 U.S.C. 461-467) and 36 CFR part 65.
Paperwork Reduction Act Statement
This information is being collected under the authority of the Historic Sites Act of 1935 (16 U.S.C. 461-467) and 36 CFR part 65.
Your response is required to obtain or retain a benefit. We will use the information you provide to evaluate properties nominated
as National Historic Landmarks. We may not conduct or sponsor and you are not required to respond to a collection of
information unless it displays a currently valid OMB control number.
Estimated Burden Statement
We estimate the time to prepare an initial inquiry letter is 2 hours, including time to maintain records, gather information, and
review and submit the letter. Average time to complete this form is 388 hours (the time varies from 256 hours to 603 hours,
depending on respondent and/or activity). You may send comments on the burden estimate or any other aspect of this form to the
Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Room 2C114, Mail Stop 242,
Reston, VA 20192. Do not send your completed form to this address.
| File Type | application/pdf |
| Author | MBaucum |
| File Modified | 2022-02-07 |
| File Created | 2022-02-07 |