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IN WITNESS'Wq[EREOF, the State and the ApPlicant have executed this <br />Agreement as of the date first above written~ <br /> <br /> Applicant <br /> <br /> By <br /> <br /> Title <br /> <br />STATE OF <br /> <br />COUNTY OF <br /> <br /> On this day of ..... 19__, personally a~peared <br />before me, the said named to me known and <br />known to me to be the person described in and who executed the foregoing <br />instrument and he (or she) acknowledged that he (or she) executed the same <br />and being duly swore by me, made oath that the statements in the foregoing <br />instrument are true. <br /> <br />My Commission expires , 19__. <br />(Signatnre of Notary Pablic) <br /> <br /> NORTH CAROLINA DEPARTMENT OF NATURAL <br /> RESOURCES AND COMMUNITY DEVELOPMENT <br /> <br /> By <br /> Secretar~ <br /> <br /> Page tl of 11 <br /> <br /> <br />