Signatur^
NC Department of Environment and Natural Resources
Middle
First
Daniel
Name:
Name:
Robert
Last Name:
Germain, Jr.
Business Address Street
Address:
265 High Street 7th Floor
City:
Morgantown
State:
Email
Phone Number:
(203) - 733-6420
Address:
Apt/Unit #: WV
ZIP Code:
26505
[email protected]
Have you ever held a landman registration or similar license in another state?
No
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Have any of these registrations or licenses ever been revoked or suspended?
No
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. There ai
I
no pendirig judgments or tax liens existing against me.
jv
Signatur^
Date:
V
09/17/2015
Page 1 of 2
NOTE: Ifthere arelinvnTiaterial changes in the information you provide on this form, please notify the Department in writing within 30 days of the change.
Middle
First
Daniel
Name:
Name:
Robert
Last Name:
Germain, Jr.
Business Address Street
Address:
265 High Street 7th Floor
City:
Morgantown
State:
Phone Number:
(203) - 733-6420
Address:
Apt/Unit #: WV
ZIP Code:
26505
[email protected]
Have you ever held a landman registration or similar license in another state?
No
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Have any of these registrations or licenses ever been revoked or suspended?
No
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. There ai
I
no pendirig judgments or tax liens existing against me.
jv
Signatur^
Date:
V
09/17/2015
Page 1 of 2
NOTE: Ifthere arelinvnTiaterial changes in the information you provide on this form, please notify the Department in writing within 30 days of the change.
