Registration To File Electronic Applications And Reports Form

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STATE OF UTAH

DOGM Approval Date:

Reset

DEPARTMENT OF NATURAL RESOURCES

DIVISION OF OIL, GAS AND MINING

Approved by:

REGISTRATION TO FILE ELECTRONIC APPLICATIONS AND REPORTS

Name:

COMPANY

Address:

city

state

zip

Has this company previously permitted, drilled, or operated wells in the state of Utah?

No ___ Yes ___

If ‘Yes’, enter DOGM Operator Account Number: N _________

Is this company currently registered with the Utah Division of Corporations to conduct business within Utah?

No ___ Yes ___

If ‘Yes’, enter Business Registration Number: ____________________

This form is to be used for the sole purpose of registering and receiving permission to file electronic applications and reports via

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the internet pertaining to the drilling or operating of Utah oil and gas wells, or service wells related to such oil and gas wells.

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Those names shown in the “Authorized Company Representatives” section are the only individuals recognized by the Utah

Division of Oil, Gas and Mining as having permission to file electronic reports in behalf of the company shown above.

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It is the responsibility of the registering company to immediately inform the Utah Division of Oil, Gas and Mining in writing of any

changes (additions or removals) to the list of authorized company representatives below.

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This form must be signed by an officer of the above company. All signatures must be witnessed by a notary public.

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This form must be mailed to:

For overnight delivery send to:

Utah Division of Oil, Gas and Mining

P.O. Box 145801

1594 West North Temple, Suite 1210

Salt Lake City, UT 84114-5801

Salt Lake City, UT 84116

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The Utah Division of Oil, Gas and Mining reserves the right to revoke permission to file reports electronically at any time.

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Failure of the above company to comply with any and all rules, recommendations, and guidelines of the Utah Division of Oil, Gas

and Mining may result in the revocation of permission to report electronically.

AUTHORIZED COMPANY REPRESENTATIVES

The following information and signatures will be kept on file with the Utah Division of Oil, Gas and Mining and will serve to attest to the

accuracy of information submitted electronically to the Division. If additional space is needed, attach a separate page. If the mailing

address of any of the individuals listed below is different than the company address shown above, attach a separate page to show their

contact information. If an individual listed below is an independent agent (not an employee of the above company), attach a separate

page with the agent’s company name and mailing address.

The following individuals hereby certify that all permit or report information that will be submitted electronically by them to the Division

is complete and accurate to the best of their knowledge and understanding.

Name (Print)

Signature

Title

Phone

Fax

Types of reports?

Applications for Permit to Drill ____

Sundry Notices ____

Well Completion Reports ____

Workover Tax Credit ____

Name (Print)

Signature

Title

Phone

Fax

Types of reports?

Applications for Permit to Drill ____

Sundry Notices ____

Well Completion Reports ____

Workover Tax Credit ____

I, the undersigned, am an officer of the above company and do hereby certify the accuracy of all information contained herein

NAME (PRINT)

TITLE

PHONE

SIGNATURE

DATE

E-MAIL

* This individual will be regarded as the main company contact and will receive a copy (via email) of all approvals unless the Division is directed otherwise in writing.

The foregoing document was acknowledged and signed before me this ____ day of ______________, 20___

(Please affix notary seal)

________________________________________________

__________________________

______________________________

Notary Public

State

County

12/2013