Applicant Name: ________________________________________ Date: _______________
Address: _____________________________________________________________________
Home Phone: _____________________ Business/Other Phone: ______________________
Email Address: _________________________________________________________________
Do you live in or own property in a Wake Forest historic district? (Check as appropriate)
Live in: ______ Own: _______ Both: _______
Which historic district? (Check all appropriate)
______Local District (North Main Street, North Avenue, and South Avenue)
______Wake Forest National Register District
______Glen Royall Mill Village District
______Downtown Wake Forest District
Occupation: __________________________________________________________________
Please list personal, professional, and organization activities related to historic preservation. These
may include restoring or rehabilitating an older house or place of business; involvement in
community preservation organizations, historical societies, or other groups working to promote
historic preservation; involvement in historic preservation as a professional architect, historian,
architectural historian, archaeologist, landscape architect, planner, anthropologist, curator,
conservationist, or folklorist; or other activities that are related to historic preservation (attach extra
sheet, if necessary). (Information required by State Historic Preservation Office.)
Revised 10-7-10
Revised 10-7-10
Please list education (especially if the applicant has a degree in a preservation-related field), skills,
training, or experience that are advantageous to the member’s work on the preservation commission
(attach extra sheet, if necessary): (Information required by State Historic Preservation Office.)
__________________________________________ ________________________
Applicant's Signature (Required) Date
Please return form to:
Town Clerk's Office
301 S. Brooks St.
Wake Forest, NC 27587
(919) 435-9419
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