Form Ogb-5 - Organization Report - State Oil And Gas Board Of Alabama

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STATE OIL AND GAS BOARD OF ALABAMA

OGB-5

Organization Report

Form OGB-5, Rev. 07/13

(File in duplicate)

This report shall be submitted every two years or immediately after any change occurs as to facts submitted.

Company name should be identical to the company name filed with the Alabama Secretary of State.

Full Name of the Company, Organization, or Individual ___________________________________________________________________________

Street Address (required) __________________________________________________________________________________________________

Post Office Address

______________________________________________________________________________________________________

City ____________________________________ County ________________________________ State ______________ Zip _______________

Phone number

Person to contact

regarding this form

Fax number

E-mail Address

Plan of organization _______________________________________________________________________________________________________

(corporation, general or limited partnership, limited liability company, sole proprietorship, or individual)

Business in which organization is engaged _____________________________________________________________________________________

If a reorganization, give name and address of previous organization _________________________________________________________________

If a foreign corporation, give

Date of Permit to do business issued

State where incorporated*

by the Alabama Secretary of State*

Name of Alabama agent* ____________________________________________________________________________________________

P.O. Address ______________________________________________ City _________________ State __________ Zip _____________

*This information must be completed if incorporated in any other state but Alabama

OFFICERS OF CORPORATION OR ALL MEMBERS OF GENERAL PARTNERSHIP,

LIMITED PARTNERSHIP OR LIMITED LIABILITY COMPANY

NAME

TITLE

POST OFFICE ADDRESS

DIRECTORS OF CORPORATION

NAME

TITLE

POST OFFICE ADDRESS

__________

________

___________________________________________________

Executed this the _______ day of __________

, 20 __

Signature

________________________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the person

whose name is subscribed to the above instrument, who being by me duly sworn on oath states that he/she is duly authorized to make the above report and that

he/she has knowledge of the facts stated therein, and that said report is true and correct.

_______

____________________

_________

Subscribed and sworn to before me this

day of

, 20

_______________________________________

SEAL

______________________

Notary Public in and for

____________________