William G. Utz

RECEIVED SEP 1 5 2014 NC Department of Environment and Natural Resource Landman Registry Application First

Middle

Name:

Name:

Last Name:

(Jb-t ?

Business Address Street

Apt/Unit#:

Address:

(-rAb

City:

State:

Phone

Email

Number:

Address:

hid

ZIP Code:

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

Ifyes, please list all states or jurisdictions where you have had such a registration or license below. Use additional paper if necessary.

Z'7 616'6

Have any of these registrations or licenses ever been revoked or suspended?

Ifyes, please list all states or jurisdictions where a similar registration or license has been suspended or revoked. MOM V

Please state, using a complete sentence, whether ornot there are any pending judgments or tax liens existing against you.

me. Signature:

Date:

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N'

in writing within 30 days of the change.

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