ADDRESS CHANGE

Individual account holders: Complete and submit the form below

GulfMark Owner Number:	*
Name On The Account:	*
Your Name (if you are not the owner):
If you are not the interest owner, a copy of power of attorney or other documentation which supports authority to make the requested Address Change is required; please email the document(s) to land@gulfmarkenergy.com. Be sure to include your account number and reference the association with an Address Change.

Old Information		New Information
Name:	*	Name:	*


Address:	*	Address:	*


City:	*	City:	*
State:	* Zip Code: - * *	State:	* Zip Code: - * *
Country:	*	Country:	*
Phone:	*	Phone:	*
E-mail:	*	E-mail:	*

TERMS OF ACCEPTANCE & SIGNATURE

I, the requestor for this Change of Address Form, warrant the truthfulness of the information provided in this submission. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Step 1: Check the box below

* By checking this box and typing my name below, I am electronically signing this change of address form

Step 2: Type in your name in the box below. A signature is required by all parties listed on the account.

*		*
First Name	Middle Initial	Last Name	Suffix