Free F-666-19 - Indiana

AGENT'S REGISTRATION
Department of Natural Resources / Division of Forestry
State Form 50312 (7-01)

Agent's Full Name (Include Middle Initial)

Street

City

State

Zip

_____________________________________ Telephone Number _____________________________________ Date of Birth

________________________________________ County of Official Residence ________________________________________ Social Security Number

The undersigned licensee understands that he or she or (if a company, trust, corporation, etc.) it is fully responsible for all of the actions of the above name agents as such actions pertain to the buying of timber, negotiating bids, writing contracts, signing contracts, or any other acts which are covered by Indiana Code 2536.5-1-1 et seq. ________________________________________________ Licensee or Officer of Company, Corporation or Trust Being Licensed ________________________________________________ Title The undersigned licensee understands that he or she comply with all provisions of Indiana Code 25-36.5-1-1 et seq., and has knowledge of such state law, and by his or her signature does agree to comply. _____________________ Date State of __________________ County of ________________ Being duly sworn upon this oath, deposes and says that he is the person who signed the above application and says that all statements in the above application are true, and said statements are made for the purpose of obtaining a Timber Buyers Agent's Card in the State of Indiana. ________________________________________________ Notary Public Signature ________________________________________________ Notary Public Printed Name Subscribed and sworn to before me, a Notary Public, in and said County and State this ____________________ day of _______________________, ____________. My Commission Expires:______________________ ________________________________________________ Agent's Signature

_____________________ Date