Seismic Permit Application Please TYPE or print LEGIBLY

Date:

Company Name & Address Individual Contact Person APPLICANT: Attn: Phone: Email:

Before issuance of a geophysical permit, the following must take place. 1. Submit with this completed application:

• Legible hard copy of map identifying C/B/S of proposed area and showing source & receiver layout • A hard copy of an Exhibit A table using the format listed below.

County Block Section Portion # Acres 2. Upon Receipt of the above, University Lands will email an invoice to the Contact Person and provide

addresses for you to email: • Word or Excel version of Exhibit A • Shapefiles of the area covered

University Lands will email a permit for signatures once all items above are received; when signed & returned by Permittee, University Lands will execute.

TYPE OF GEOPHYSICAL SURVEY: 2D ($2,400/mile will be invoiced) 3D ($16/acre will be invoiced) Microseismic ($400/mile will be invoiced)

JOB NAME (if applicable): PARAMETERS UTILIZED IN OPERATION: (Source & Receiver data)

CONTACT INFORMATION: Company Name & Address Individual Contact Person PERMITTEE: Attn: (Company retaining geophysical data upon completion)

Phone: Email:

GEOPHYSICAL COMPANY: Check here is same as applicant

Attn: Phone: Email:

OIL & GAS COMPANY:

Attn: Phone: Email:

OTHER: Attn: (if applicable) Phone: Email:

OTHER: Attn: (if applicable) Phone: Email:

***FOR UNIVERSITY LANDS USE ONLY***

UL Land Staff Recommendation: Approved Permit #_____________

Initials: Not Approved