JOIN THE COALITION
Name:
Mailing Address (road,city,state,zip):
Property Address (road,city,state,zip):
Township:
Benton
Fairmount
Fishing Creek
Greenwood
Jackson
Madison
Millville
Mt. Pleasant
Orangeville
Pine
Ross
Sugarloaf
Stillwater
Other
Number of Acres Owned (5 or more only):
Parcel Numbers:
Have you been contacted by any oil/gas company?:
YES /
NO
What company / When?:
Have you signed a gas lease?:
YES /
NO
Home Phone:
Cell Phone:
Best Time to Call:
Email: