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Department of Interior <br />Office of Surface Mining, Applicant Violator System <br />Certification for Organizational Family Tree (OFT) Submission <br />Attach a supplemental sheet if you are registering for more than one OFT <br />I, AmF-3 M- i CErZ , certify that I am a duly elected representative of <br />serving in the capacity of Z�r r"'g 1-1 -F <br />and as such, authorize the Contact Person identified below to deliver the Organizational Family Tree and all changes to <br />such to the Office of Surface 'ng, Applicant ' <br />Authorizing Signature: ate: J A O 3 Z O t 3 <br />Official Title: <br />Company Name M)AJtx1C, Z,0 <br />Address Pa 0"Z"K J g -4 <br />Address <br />City CRA 1C. <br />State zip b «Z <br />TIN SZZ�� !^^ _:V91 Entity # <br />Contact Name I/; c%Cr <br />Contact Phone Z(. `/-U <br />E -mail address <br />Supplemental sheets attached? Y/N <br />Note: Applicant Company should complete all items <br />Please complete and mail to: Office of Surface Mining <br />AVS <br />2679 Regency Road <br />Lexington, KY 40503 <br />