The Blacksmith Institute: Site Nomination Form

Mercury Program:

Lead Program:

Chromium and
Tanneries Program:

Projects By:

Site Nomination Form

Please fill out the following form and click the submit button at the bottom of the page.

Refer to our guidelines and sample form for assistance in filling out the form. Send any additional attachments to nominations@pollutedplaces.org

(** indicates required fields)

**Nominator
Organization
Phone
Fax
**Email
Web Site
**Site Name
Site Town
**Site Country
Site Region
**Site Description (eg: history, key players, etc.)
Population Affected (NOTE: We focus on sites with substantial, demonstrated human health effects)
Toxin (type of pollutant, observed health effects, area affected, etc.)
Current efforts underway to address the problem
Remediation strategy most likely to succeed
Local contacts (local government agencies, NGOs, etc.)
How did you hear about our organization? (via web, NGOs, media coverage, etc.)
Relevant web links / additional information