JotForm

First Name: *

Last Name: *

Address: *

Address (con't):

City: *

State: *

Zip Code: *

E-Mail Address: *

Phone Number: *

Work Phone:

Fax Number:

Best Time to Call:

Type of Interest Owned:

Approximate Monthly Income:

Payments Received From:

Property Location (State):

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: