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Centennial Awards Program
Please type or print legibly
Organization must have operated continuously in Illinois for
100 years or more
Please
note: THERE IS A $50 NON-REFUNDABLE APPLICATION FEE
(Fee may be paid via check to ISHS or click here to pay online)
Current Legal Name of Business:
____________________________________
Name
and title of contact person:
____________________________________
Mailing Address:
_______________________________________________
City
and ZIP Code: _______________________
Telephone: ____________
e-mail address: _________________________
Location address (if other than mailing):
______________________________
Name
and title of organizational head:
_________________________________
Founding date: ______
Original location (if different) __________________
Current nature of institution:
________________________________________
Please describe any changes in ownership or status: _____________________
___________________________________________________________________
VERIFICATION OF FOUNDING DATE REQUIRED FOR THIS PROGRAM!
(See
below for acceptable documentation to verify your company’s
history)
FOR
OFFICE USE ONLY Rev. 3/04
Date
received: _____________________
Application fee enclosed: ____________
Comments: ________________________
Documentation verified:
____________
Photos
received: _______
Plaque ordered:
__
Reservations
Acceptable Documentation
To verify the founding date and change of
name of your institution, primary source documentation is
needed. One or more of the following are acceptable if the contain dates:
Unacceptable documentation
Photocopies are acceptable. Originals, if sent, will be returned upon request, unless you would like to donate them to the Illinois State Historical Society.
PLEASE NOTE: Copies of slides are not required but are useful in helping us publicize your accomplishments. Slides or prints might include your original founder, original and/or current building, original and/or current produces or services.
Your local or county historical society or public library might be helpful in locating documentation. Call us if you need a name or phone number.
Send this completed application form and
verifying documents on or before
Illinois State Historical Society Centennial Awards Program 210 1/2 South Sixth Street, Suite 200 Springfield, IL 62701-1503 Phone: (525)-2781 Fax: (217) 525-2783
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tcameron@historyillinois.org
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