National Register of Historic Places Plaque/Certificate Order Form

NATIONAL REGISTER OF HISTORIC PLACES
PLAQUE/CERTIFICATE ORDER FORM

Official name of property

Include Historic District

name, if applicable

(Note: The official name is the name under which the property is listed in the National Register and must be used on the plaque and/or certificate. Please do not alter or add to it. If you are unsure about the property’s name or listing status please contact our office before sending in your payment.)

Cost of plaque: $180.00 Check box for each item you are ordering.

Price includes engraving, shipping, sales tax Plaque Certificate

Cost of certificate: Free of charge

Purchaser’s name and

mailing address

E-mail address

Telephone

Purchaser’s signature ______Date______

Print and sign the order form and return with your check or money order made out to the

South Carolina Department of Archives History

Mail to: South Carolina Department of Archives History

National Register Plaques

8301 Parklane Road

Columbia, SC 29223-4905

Questions? Call 803-896-6172 or e-mail

Revised July 15, 2016