Plans for proposed installations are to be submitted to, and shallmeet the approval of ,North Carolina Railroad Company (NCR). Applicant shall enterinto an occupancy agreement with NCRR before any construction activities commence on site .materials and installation are to be in strict accordance with specification of the American Railway Engineering and maintenance -of-way Association (AREMA),North Carolina Railroad company, and the operating railroad(Norfolk Southern Corporation and/or CSK Transporation as appropriate). The information submitted with this signed application and the required number of copies shall be per the Pipeline and Underground/Aerial Occupancy Application instruction (NCRR Form 230) The engineering application fees to be submitted with this application are as started in current engineering fee sechedule(HN-02)

1. Owner's Legal Name :

*please Ensure that the exactlegal name is provided with no Abbreviation.

2. Owner Street Address Name

city :

State :

zip :

3. Owner Mailing Address:

Street Address P.O/BOX:

city :

State :

zip :

4.Name of Owner's Representative:

Title:

Street Address:

city :

State :

zip :

Email:

Telephone Number:

Ext:

5. Name of Owner's Contact for billing purpose:

Title:

Street Address:

city :

State :

zip :

Email:

Telephone Number:

Ext:

6.Billing:owner prefer

yearly or

one time non assignable payment of occupany fees

7. Owner is A

Corporation-State of formation:

Limited Partnership-state of formation:

Limited Liability Company-State of formation:

Generel partnership-State of formation:

sole properietership-State of formation:

Indivisual-State of formation:

Goverment Entity-State of formation:

Other-State of formation:

8. Company name

9. Contact person name:

Title:

Street Address:

city :

State :

zip :

Email:

Telephone Number:

Ext: