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Ifyes, please list ait states or jurisdictions where you have had such a registration or license below. Use additional paper if necessary. RECEIVh 3. OCl 27 ZOfj.

NC Department of Environment and Natural Resources Landman Registry Application First

Middle

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Name:

Last Name: Name:

Business Address Street

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Address:

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City:

Apt/Unit #: N. C .

State:

Phone

Email

Number:

Address:

ZIP Code:

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Have you ever held a landman registration or similar license in another state?

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If yes, please list ait states or jurisdictions where you have had such a registration or license below. Use additional

paper if necessary.

RECEIVh 3 OCl 2 7 ZOfj

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OIL &GAS PROGftAM Have any of these registrations or licenses ever been revolted or suspended?

If yes, please list all states or jurisdictions where a similar registration or license has been suspended or revoked.

Please state, using a complete sentence, whether or not there are any pending judgments or tax liens existing against you.

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Signature^"^^^ ^

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Date: loj^pji^

2^ Page 1 of 2

NOTE: Ifthere are any material changes fn the Information you provide on this form, please notify the Department in writing within 30 days of the change.

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