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STRATFORD BLUE PLAQUE PROGRAM NOMINATION FORM

Name of Nominee (s):

Please confirm that the nominee(s) has been deceased for at least 5 years

Yes

Profession (if applicable):

Proposed Plaque address:

Reasons for Nomination – What is the Story behind this Nomination?

This nomination for the Stratford Blue Plaque Program is submitted and endorsed by:

Name of individual or group:

Address:

Phone:

E-Mail:

Date:

Position (if group nomination):

Signature:

Clear