DATE: ______________

NAME:____________________________________________________________

ADDRESS:_________________________________________________________

CITY: ____________________STATE/PROV:______ZIP/POSTAL CODE:_______

PHONE: ________________FAX:_______________ E-MAIL _________________

NUMBER OF YEARS OF PARTICIPATION AS:

PLAYER_____________MANAGER___________ADMINISTRATOR_____________

OFFICIAL_____________AREA OF PARTICIPATION________________________

SUBMITTED BY:____________________________________________________

ADDRESS:_________________________________________________________

CITY______________________STATE/PROV:_______ZIP/POSTAL CODE:______

PHONE:________________FAX:_____________E-MAIL:____________________


DEADLINE IS MAY 1. PLEASE ATTACH A RESUME OF YOUR NOMINEE FOR THE I.S.C. HALL OF FAME ON A SEPARATE PAGE. SEND ALONG WITH THIS FORM TO:

ROYCE HEATH, CHAIRMAN
I.S.C. HALL OF FAME COMMITTEE
P.OL BOX 186
IREDELL, TX 76649

PHONE: 254-364-2605
FAX:: 254-364-2717
E-MAIL: rpheath@htcomp.net