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.
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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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Date: loj^pji^
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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.