DATE: 

TO:  Nevada Heritage
        7875 North Claridge Pointe Parkway,
        Reno, Nevada  89506

FROM: 

        ______________________

        ______________________

        ______________________

I am submitting the following information for inclusion in the Nevada Heritage Web Site. To the best of my knowledge the information and/or pictures that I am submitting are not copywrited or protected in any way from display on the internet.

    Type of Submission:

    Summary of Content and Where Obtained From:

Please give me a personal (   ) business (   ) web page.  I have attached additional information for this purpose.  

I may be contacted at:

    Address:

    Phone:

    FAX:

    E-mail

    (      )  Check here if you do not want any information about yourself displayed on Nevada Heritage.

______________________________ Date: ________
                        /Signature/