NCC230040_FRO Submitted (2)_20230113

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(c) In order to facilitate Express Permitting, it is necessary to be able to contact the Engineer or other
consultant who can assist in providing any necessary information regarding the plan and its preparation:
The Cullipher Group, PA [e-mail]
Engineering Firm or other consultant E-mail Address
Chase Cullipher 252-773-0090
Individual contact person (type or print) Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided by me
under oath (This form must be signed by the Financially Responsible Person if an individual or his attorney -in -
fact, or if not an individual, by an officer, director, partner, or registered agent with the authority to execute
instruments for the Financially Responsible Person). 1 agree to provide corrected information should there be
any change in the information provided herein.
Keith Wal�* President
Type r r'nt am n Title or Authority
Sign9tdr'ev - - Date
-I/)Y,- 6 �� � , }� 0,5 i� L /�-/-I( , a Notary Public of the County of &)/c
State of North Carolina, hereby certify that %k,�4t appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and no rial seal, this May of /i'�/� , 20 /
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aMy commission expires
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