20231675 Ver 1_Agent Authorization form_Rognstad to USFWS_20231206

AGENT AUTHORIZATION FORM
PROPERTY LEGAL DESCRIPTION:
LOT NO.
PLAN NO, PARCEL ID: Pin: 03118162, PIN: 03118103,
03118134,
STREET ADDRESS: 665 William T Calloway Road, Todd, NC 28684
Print:
Property Owner: Ronald L. Rognstad or Ron Rognstad
Property Owner: Shari A. Rognstad
The undersigned, registered property owners of the above noted property, do hereby authorize
Laura Fogo of U.S. Fish and Wffdfffe Service
(Contractor / Agent)
(Name of consulting firm)
to act on my behalf and take all actions necessary for the processing, issuance and acceptance of
this permit or certification and any and all standard and special conditions attached.
Property Owner's Address (if different than property above):
665 William T. Calloway Road, Todd, NC 28685
Telephone: [phone]_or336-620-1954 or336-846-4491
We hereby certify the above information submitted in this application is true and accurate to the
best of our knowledge.
I/ Z24
Authorized Signature Authorized Signature
Date: t' Date: