received
received SEP 3 0 2014 NC Department of Environment and Natural Resources Landman Registry Application
PFMR/DEMLR ni
First
Middle
Name:
Name:
Last Name:
nAS PROGKA \l\
po iicy-
Business Address Street
Address:
City:
0 'Dec:ir _5p / ('s/j c/rw
Apt/Unit it: State:
Phone
Email
Number:
Address:
A^orfh Carolina
ZIP Code:
7C6\r6i\'n(i{ i rr,
Have you ever held a landman registration or similar license in another state?
Ifyes, please list all states or jurisdictions where you have had such a registration or license below. Use additional paper if necessary.
Have any of these registrations or licenses ever been revoked or suspended?
|
Ifyes, 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.
X do noi
<X1^
Signature:
Date:
Page 1 of 2
NOTE: Ifthere are any material changes in the information you provide on this form, please notify the Department in writing within 30 days of the change.
PFMR/DEMLR ni
First
Middle
Name:
Name:
Last Name:
nAS PROGKA \l\
po iicy-
Business Address Street
Address:
City:
0 'Dec:ir _5p / ('s/j c/rw
Apt/Unit it: State:
Phone
Number:
Address:
A^orfh Carolina
ZIP Code:
7C6\r6i\'n(i{ i rr,
Have you ever held a landman registration or similar license in another state?
Ifyes, please list all states or jurisdictions where you have had such a registration or license below. Use additional paper if necessary.
Have any of these registrations or licenses ever been revoked or suspended?
|
Ifyes, 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.
X do noi
<X1^
Signature:
Date:
Page 1 of 2
NOTE: Ifthere are any material changes in the information you provide on this form, please notify the Department in writing within 30 days of the change.
