Form Mrw Reg - Registration For Mineral Royalty Withholding (Mrw) (Page 2 of 3) in pdf

Form Mrw Reg - Registration For Mineral Royalty Withholding (Mrw) Page 2

9. Purpose of Registration

Initial Registration

Started New Business

Purchased Existing Business or Property

Re-registration

Entity Change

Other (Please attach explanation.)

10. List the previous name, owner and date acquired if you purchased an existing business, or the previous name if there

is a business name change.

Previous Business Name ___________________________________________________________________

Previous Owner __________________________________________________________________________

Date Acquired __________________________

11. Type of Mineral Production (Indicate all that apply.)

Oil

Gas

Coal

Other Mineral (Please indicate.) _________________________________________________________

12. Signature of Owner, Partner or Ofﬁ cer (Unsigned forms will be returned.)

____________________________________________________________

Date ______________________________ Phone Number ______________________________

Email ___________________________________________

13. Print the name of the owner, partner or ofﬁ cer who signed on line 12.

___________________________________________________________________________________________

Form Mrw Reg - Registration For Mineral Royalty Withholding (Mrw) Page 2