Rolling at The Tower Ballroom Submissions

1

NameIf you would like to remain anonymous, please skip this question.

First Name

Last Name

2

EmailIf you would like to remain anonymous, please skip this question.

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3

Phone NumberIf you would like to remain anonymous, please skip this question.

Area Code

Phone Number

4

AddressIf you would like to remain anonymous, please skip this question.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

6

Please tell us your memory of roller skating at The Tower Ballroom

7

Please upload images of any photos/memorabilia that you haveYou may upload multiple files if required

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8

I confirm that I am happy for my story and images to be used by Bertz Associates for the Rolling at The Tower Ballroom project* This field is required.

YESNO

9

I confirm that I am happy to be contacted by Bertz Associates regarding my submitted story* This field is required.If you wish to remain anonymous and have not provided contact information, please select no.

YESNO