Nomination Form

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Nomination Form

Complete as much of the requested information as possible. Leave blank what you are not sure of or do not know. Return the form to the Scott Somershoe, State Ornithologist, Tennessee Wildlife Resources Agency, P. O. Box 40747, Nashville, TN 37204 or Scott.Somershoe@state.tn.us. Thank you for participating.

Name of Site: _______________________________________________________________________________________

Location (including nearest town/county): ______________________________________________________________

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Description of Site (habitats, prominent features, etc.): ___________________________________________________

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Geographical coordinates (center of site): Lat. _________________________ Long. __________________________

Elevation Range (feet): Low_________ High__________ Size (acres): _______________

USGS 7.5’quad used to delineate site: __________________________________________________________________

Conservation Concerns: Classify as C (Critical), S (Serious), M (Major), P (Potential).
___Natural pests/disease   ___ Water pollution    ___ Air pollution    ___ Disturbance to birds (specify how)
___Commercial development    ___Residential development    ___Recreational development/overuse
___Hunting conflict    ___Fishing conflict    ___Introduced plants/animals    ___Deforestation    ___Forestation
___Extraction (mining/quarries)    ___Succession     ___Overgrazing    ___Pesticides
___Agricultural conversion   ___Predation   ___Damming    ___Drainage    ___Channelization
___Other _______________________________________________________________________
___Other _______________________________________________________________________

Site Selection Criteria: Check appropriate boxes. See Criteria For Site Selection for detailed description of each category.

q 1. Endangered or Threatened species
q 2. In Need of Management species
q 3. Rare/Unique/Representative Habitat
q 4a. 500+ waterfowl winter or migration
q 4b. 25+ breeding pairs waders or 100+ individuals feeding/staging

q 4c. 1000+ migratory raptors (seasonal)
q 4d. 500+ shorebirds in migration
q 4e. 1000+ gulls or 100+ terns in winter or in migration
q 4g. Single species concentration
q 5. Long-term research and/or monitoring

Supporting ornithological data on categories checked in "Site Selection Criteria." Data needs to be no older than seven years, preferably five years and less. Use additional sheets if needed. Also submit any additional supporting data.

Site Criteria	Species/ Group	Season¹	Avg. No Season	Max. No. Season	Years of Data	Source²
Ex: 4a.	Waterfowl	W	6,000	15,000	’97-’03	3,5,6

Season¹ B = Breeding, W = Wintering, SM = Spring Migration, FM = Fall Migration
Source ² 1-Atlas Breeding Birds of Tennessee 2-Breeding Bird Surveys 3-Christmas Bird Counts
4-Point Counts 5-Refuge Counts 6-Personal observations 7-Other (specify)

Land owner(s) and contact information, if known: ______________________________________________________

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Submitted by and contact information: Name ___________________________________________________________

Address _____________________________________________________________________________________________

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Telephone _______________________________________ E-mail _____________________________________________

Names of individuals contributing to nominated site: ____________________________________________________

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Date ______________________________________

This page was last updated on 02/19/06.