First Name:
*
Last Name:
*
Address:
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Address (con't):
City:
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State:
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Please Select
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Alaska
Arizona
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Zip Code:
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E-Mail Address:
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Phone Number:
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Work Phone:
Fax Number:
Best Time to Call:
Please Select
9:00am - 12:00pm
12:00pm - 5:00pm
After 5:00pm
Type of Interest Owned:
Please Select
Mineral Interest
Royalty Interest
Working Interest
Not Sure
Approximate Monthly Income:
Payments Received From:
Property Location (State):
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Property Location (County):
Previous Owner (If Known):
Other Comments:
If you are currently receiving a monthly royalty check, please scan and attach copies of your last three check stubs below. Alternately, you may also sent them to dwarren@lomocoinc.com or fax them to (903)592-5983.
Check Stub 1:
Check Stub 2:
Check Stub 3:
Submit
Should be Empty: