Authority Organization Form
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1
2OHIO DEPARTMENT OF NATURAL RESOURCES
DIVISION OF OIL & GAS RESOURCES MANAGEMENT
2045 MORSE RD., F-2, COLUMBUS, OH 43229-6693 • (614) 265-6922
AUTHORITY & ORGANIZATION FORM (Form 9)
1. OWNER NUMBER:
2. NAME & MAILING ADDRESS:
5. PURPOSE OF FILING:
☐
NEW OWNER
☐
ADDRESS AND/OR TELEPHONE CHANGE
☐
CHANGE OF AUTHORIZED AGENT
☐
CHANGE OF STATUTORY AGENT
EMAIL:
☐
TEMPORARY PLUG ONLY
PHONE NUMBER:
☐
NAME CHANGE
CELL PHONE NUMBER:
6. CURRENT ORGANIZATION:
☐
FAX NUMBER:
CORPORATION
☐
3. STREET ADDRESS:
LIMITED PARTNERSHIP
☐
LIMITED LIABILITY CORPORATION
☐
LIMITED LIABILITY PARTNERSHIP
☐
PARTNERSHIP
4. IF ORGANIZATION IS A SUBSIDIARY OR AN ASSUMED NAME (dba),
☐
TRUST
PROVIDE NAME & ADDRESS OF ASSOCIATED COMPANY:
☐
SOLE PROPRIETORSHIP
☐
JOINT VENTURE
☐
OTHER: ______________________________________________
7. EXEMPT DOMESTIC WELL OWNER (see criteria on back of form) NOTE: Exempt domestic well owner only complete boxes 2, 3, 5, and 7.
☐
☐
YES
NO
IF YES, PLEASE PROVIDE NUMBER OF ACRES: ______________________________________________________________________________
8. IF A REORGANIZATION, PROVIDE NAME AND ADDRESS OF PREVIOUS ORGANIZATION:
9. LIST NAME AND STREET ADDRESS OF AUTHORIZED AGENT AND ENCLOSE A COPY OF CERTIFICATE OF APPOINTMENT:
EMAIL:
PHONE NUMBER:
FAX NUMBER:
CELL PHONE NUMBER:
10. LIST NAME AND STREET ADDRESS OF STATUTORY AGENT (Corporations only):
EMAIL:
PHONE NUMBER:
FAX NUMBER:
CELL PHONE NUMBER:
I, the undersigned, being first duly sworn, depose and state under penalties of law, that I am authorized to complete this Authority and
Organization Form on behalf of the organization listed above, that this form was prepared by me or under my supervision and direction, and that
date and facts stated herein are true, correct, and complete to the best of my knowledge.
That I hereby agree to conform with all provisions of Chapter 1509, ORC, to all orders and rules issued by the Chief of the Division of Oil and Gas
Resources Management.
SIGNATURE OF AUTHORIZED AGENT: ______________________________________________________________________________________________
TITLE: ____________________________________________________________________________________________________________________________
NAME (Typed or Printed): ___________________________________________________________________________________________________________
SWORN to and subscribed before me this __________________ day of _______________________________________________ , 20______________
_________________________________________________________________
(SEAL)
(Notary Public)
_________________________________________________________________
(Date Commission Expires)
NOTE: A certificate issued by an insurance company stating the owner has in force a combined (general aggregate): $1 million bodily injury
coverage and property damage for well(s) located in non-urban areas, $3 million bodily injury coverage and property damage for well(s) located in
urban areas*, or $5 million bodily injury and property damage for owners of a horizontal well(s). The certificate MUST BE ATTACHED or on file at
the Division of Oil and Gas Resources Management UNLESS YOU QUALIFY AS AN EXEMPT DOMESTIC WELL OWNER.
* Check the 2010 Census information found at
oilandgas.ohiodnr.gov/Urban-Drilling-Requirements
to determine if your well is located in an urban area.
DNR 5618 (REV513)
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