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RECEIVED JUN 0 3 2014 NC Department of Environment and Natural Resources Landman Registry Application First Name:

Middle

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Last Name:

Business Address Street

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Apt/Unit#:

Address:

City: Phone

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State:

ZIP Code:

Email

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Address:

Number:

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

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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Have any of these registrations or licenses ever been revoked or suspended?

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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

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