1150 EXPLORATION GEOPHYSICS 



RECEIPT AND RELEASE 



, 19. 



RECEIVED from (company) the sum of 



DOLLARS ($ ) which acknowledge to be in 



full settlement and discharge of a claim growing out of property damage sustained 



by on or about , 19 , for which 



damage have claimed the said (company) 



to be legally liable, and in consideration of said sum so paid to , 



hereby remise, release and forever discharge the said , and 



its employees from any and all actions, causes of action, claims and demands for, 

 upon or by reason of any damage or loss which heretofore has been or which here- 

 after may be sustained by in consequence of 



WITNESS hand and seal the day and year first 



hereinabove written. 



Witness. 

 Address. 



Witness. 

 Address. 



