NEDA APPROVAL NO.

A 0729 10200 R 050 B

REPUBLIC OF THE PHILIPPINES

NATIONAL HISTORICAL COMMISSION OF THE PHILIPPINES

Identification of Significant Historical Structure

Entry Number: _________

Region:

Province:

Date:
Type:

___________
Number:

1. NAME
Common:
And/or historic:

2. LOCATION
Street and number:
Barangay/Barrio:
City/Town:

Province:

3. CLASSIFICATION
Category
Building
Structure
Site

[]
[]
[]

Present Use
Shrine
[]

Region:

Ownership
[]
[]
[]

Private
Both
Public

Commerce

[]

Status

Public acquisition:
[]
In progress
Being considered [ ]

Industrial

Occupied
Unoccupied
Preservation work in
Progress
[]

Ecclesiastical

[]
[]
[]
[]

Others (Specify)

____________
____________
____________

Monument

[]

Education

[]

Health

[]

Museum

[]

Landmark

[ ]

Entertainment

[]

Private Residence

[]

Scientific

[]

Agriculture

[]

Government

[]

Military

[]

Transportation

[]

4. OWNER OF PROPERTY
Owners Name:
Street and Number:
City/Town:

Province:

5. LOCATION OF LEGAL DESCRIPTION

Registry of Deeds: National Archives, Bureau of Buildings, etc.
Street and Number:
City or Town:
Approximate area of property (square meters)

Province:

Accessible to the
Public
Yes [ ]
No [ ]

6. DESCRIPTION
Condition

Fair [ ]

Excellent [ ]

Good [ ]

Altered

(Check one)
Unaltered [ ]

Integrity
[]

Deteriorated [ ]

Describe the present and original (if available) physical appearance

7. LOCATION PLAN (Attach other photographs and sketches)

Moved [ ]

Ruins [ ]

Unexposed [ ]

(Check one)
Original Site [ ]

8. SIGNIFICANCE
Period:
Spanish [ ]

American [ ]

Post-War [ ]

Specific Date (s)

Areas of Significance (check one or more as appropriate)
[]
Commerce
Architecture
[]

Political

[]

Communications

[]

Literature

[]

Religion

[]

Education

[]

Military

[]

Science

[]

Engineering

[]

Music

[]

Sculpture

[]

Industry

[]

Painting

[]

Social/Humanitarian

[]

Landscape

[]

Philosophy

[]

Theater

[]

Statement of Significance (Include Personages, Dates, Events, Etc. )

Transportation

[]

Urban Planning

[]

Others (Specify)

[]

________________________
________________________

9. MAJOR BIBLIOGRAPHICAL REFERENCES

10. FORM PREPARED BY

Name:
Organization and Designation: