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History Project Form
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  Berks County History Project
     Submission Form

     "Follow the How to Guide for Instructions"

 

TIP for completing form:

This form requires some time to complete fully and cannot be saved
and returned to at a later time.  To save time, you can prepare the "Story" 
section in any text editor and then cut and past it into the form.    

 
Last Name 

First Name

Middle Name

Maiden Name



Main Category 



Additional Categories 

(Select only one)

(Mark multiple categories by holding down control key and selecting)







FAMILY HISTORY:
Dates of Residency in Berks
Location(s) of Residency in Berks
Full Name of Spouse(s)
Number of Children
Parents Names
(Include mother's maiden Name)
Number of Siblings


PERSONAL INFORMATION:
Date of Birth
Formal Education:  Schools 
and/or Trade Schools
Degrees
Year Graduated if Known
Informal Education:   Private
Lessons for Music, Art, etc.
Honors and Awards


TELL THE STORY - Please provide as many specific details, including dates, places and names, as possible regarding important events related to any category(categories) listed above. 


What accomplishment are you most
proud of?

If deceased . . .
     Date of Death
     Place of Death
     Place of Burial


  CONTRIBUTOR INFORMATION:
       Full Name
       Address
       City
       State / Zip     
       Phone
       Email Address:
       Relationship to Subject: Self        
       Date Submitted
   


USAGE AGREEMENT
I understand that the purpose of the Berks Women's History Project is to collect and catalog information about women of Berks County which will be used for scholarly and educational purposes; that the Berks County Commission for Women plans to retain the information in its permanent collection and that the materials may be used for exhibition, publication, presentation on the World Wide Web and succesor technologies, and for promotion of the Women's History project and its actIvities in any medium.  This agreement does not give up any copyright or performance rights that I may hold.  I also grant permission for any photographs provided by me or taken of me in the course of this collection to be used, published and copied by/for the Women's History project in any medium.
I ACCEPT USAGE AGREEMENT  

 

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