Prefix
First:
Middle:
Spouse:
Last:
Suffix:
Mailing Address:
Email:
Telephone (XXX) XXX-XXXX:
Property Address:
City:
State:
ZIP:
Parish/County:
TAX GEO # or Other:
Township: Range: Section: Subsection: Lot:
Legal Description:
Property Type:
Owner Interest:
100% or Other:
Drill Site:
Yes No
Acreage:
Mapping:
Yes No
 
Notes:
Problems:
 Yes No
 
Mortgage:
 Yes No Mortgage Company:
Date Joined:
Option Chosen:
Payment Status:
First Year Second Year Third Year
Yard Sign:
 Yes No
Referred By:
 Referral Fee Paid: Yes No
Subdivision:
Subdivision Leader:
Section Leader:
Lease Negotiated:
 Yes No
Start Date of Lease:
Bonus Amount:
Date Commission was Paid:
Commission Amount: