Esher Residents Association

Esher Residents Association Blue Plaque Nomination Form

Who do you think should receive a blue plaque? Make your nomination here.

For guidelines on who and what is eligible to be nominated for a Blue Plaque, please read the Blue Plaque Guidelines on our website (www.esher-residents.com). Peter Hills can be contacted (Peter.hills7@btinternet.com) if you wish to discuss your nomination.

The list of nominations will be published on the Esher Residents Association website and updated as progress is made.

Please fill in each of the fields below but, in any event, complete your personal details at the end of the form (Number 7) so that we may contact you if necessary.

1. Full name and title of nominated person:

2. Nominated place/building (within Esher) :

Address 1

Address 2

Address 3

3. Nominee's relationship to the address? Please tick one only:

Lived Here	Worked Here
Studied Here	Business Here
Other (please give details below

Details

4. Dates:

Date of Birth of nominee

Dates at which nominee was associated with address/site

5. What are your nominee's achievments and/or contributions that the plaque will recognise?

6. Suggested wording on the plaque?

7. Your details (please complete all fields):

Name :
Email address :
Telephone :
Mobile :
Address1 :
Address2 :
Town :
Post Code :
Comments you may like to add?