Bureau of Historic Preservation | R.A. Gray Building | 500 Bronough Street | Tallahassee, FL 32399-0250
Tel: (850) 245-6333 or 1-800-847-7278 | Fax: (850) 245-6437
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Revised Feb. 8, 2019
BHP Use Only | Site Number: Date recieved: Reviewer:
NATIONAL REGISTER OF HISTORIC PLACES
PRELIMINARY SITE INFORMATION QUESTIONNAIRE
FLORIDA DEPARTMENT OF STATE - LAUREL M. LEE - SECRETARY OF STATE
This questionnaire is intended only to provide preliminary information about the property to the Bureau of Historic Preservation.
Name and Location of Property
Name:
Address:
City:
Zip Code: County:
Name and Address of Owner
Name:
Address:
City:
State: Zip Code:
I support this effort to list or seek a determination of eligibility for listing my property on the National Register of Historic Places:
Yes No
Owner Signature and Date: Phone:
Property Information
Significant Dates (construction, events, etc.):
Has it been moved?
Yes No
Year moved:
Original use: Current use:
Property Type
Archeological or
Historic Site
Residential
Building
Commercial
Building
Industrial
Building
Public Building Other (describe)
Property Description:
Describe the design, construction, and general condition of the building. Indicate any architecturally significant features, unique
materials, and alterations to the building. (If space below is insufficient, attach additional sheets of paper)
Why is the property significant?
Provide a basic history of the property. Indicate significant events, people, or architectural styles associated with the property.
(If space below is insufficient, attach additional sheets of paper)
Required Enclosures:
Current photos (exterior and interior)
Historic photos (if available, photocopies acceptable)
Location map (and site plan for large properties)
Sketch floor plan
Proof of ownership (property appraiser record or notarized
letter)
Submitter's Name and Address
Name:
Address:
City:
State: Zip Code:
Email:
Phone:
Date: Signature:
