Michael A. Lynch-Blosse
LM#40
NC Department of Environment and Natural Resources Landman Registry Application First
Middle
Name:
Name:
Last Name:
Business Address Street
Address:
2/2 //c/StW
City:
State;
CC&/)
Phone Number:
Apt/Unit #:
(7/3)
//(>
ZIP Code:
29739
Email Address:
Have you ever held a landman registration or similar license in another state?
If yes, 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Have any of these registrations or licenses ever been revoked or suspended?
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.
Signature:
Date:
/
/ /
5^--^F^age 1of 2
NOTE: If th^e are any material dhanges inthe information you provide on thisform, please notify the Department in writing within 30 days of the change.
NC Department of Environmental and Natural Resources Landman Registry Application
Have you ever held a landman registration or similar license in another state?
I have held the following certifications/licenses: • •
Certified Petroleum Geologist #2978 (AAPG - 40 Year Member) Texas Board of Professional Geoscientist License #5279 (through 2013)
I'm an oil and gas professional with more than thirty five years of diversified experience with major and leading independent energy producers and as an industry consultant. This work involved all phases of exploration and development working with multidisciplinary teams, including the directing of land and leasing activities. 1am also a member of various Geoscience and oil and gas organizations.
I
7
Michael A. Lynch-Blosse
August 28, 2014
NC Department of Environment and Natural Resources Landman Registry Application First
Middle
Name:
Name:
Last Name:
Business Address Street
Address:
2/2 //c/StW
City:
State;
CC&/)
Phone Number:
Apt/Unit #:
(7/3)
//(>
ZIP Code:
29739
Email Address:
Have you ever held a landman registration or similar license in another state?
If yes, 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Have any of these registrations or licenses ever been revoked or suspended?
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.
Signature:
Date:
/
/ /
5^--^F^age 1of 2
NOTE: If th^e are any material dhanges inthe information you provide on thisform, please notify the Department in writing within 30 days of the change.
NC Department of Environmental and Natural Resources Landman Registry Application
Have you ever held a landman registration or similar license in another state?
I have held the following certifications/licenses: • •
Certified Petroleum Geologist #2978 (AAPG - 40 Year Member) Texas Board of Professional Geoscientist License #5279 (through 2013)
I'm an oil and gas professional with more than thirty five years of diversified experience with major and leading independent energy producers and as an industry consultant. This work involved all phases of exploration and development working with multidisciplinary teams, including the directing of land and leasing activities. 1am also a member of various Geoscience and oil and gas organizations.
I
7
Michael A. Lynch-Blosse
August 28, 2014
