S\gr\zX.uxQ\/^/^ _ Date: 7/^^//

received JOL 2 9 lOH NC Department of Environment and Natural Resources

Middle

First Name:

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Name:

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Last Name:

Business Address Street

Address:

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Apt/Unit #:

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ZIP Code:

State:

City: Phone

Email

Number:

Address:

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

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If yes, piease list all states orjurisdictions where you have had such a registration orlicense below. Use additional naoer if necessarv.

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Have anyof these registrations or licenses ever been revoked or suspended?

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

Please state, using a complete sentence, whether or notthere are any pending judgments or taxliens existing against you.

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_

Date: 7/^^// ^

in writing within 30 days of the change.

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