New Royalty Entity Request Form
PDF Version (23 Kb, 1 Page)
Excel Version (907 Kb, 1 Page)
Suite 100, 9911 Chiila Blvd
Tsuu T'ina, AB T2W 6H6
Ph: (403) 292-5625
Fax: (403) 292-5618
A
GRANTEE COMPANY CODE ____________
GRANTEE COMPANY NAME ____________
DATE SUBMITTED YYYY MM DD ____________
WELL NAME ____________
WELL LOCATION:
| LE | LSD | SEC | TWP | RGE | W | M | EVT |
|---|---|---|---|---|---|---|---|
B - Well Working Interest Ownership for Royalty Payment Purposes
Royalty Payor #1
Royalty Working Interest Owner:
________________________
company name
_________________________
company code
Address:
_________________________
street
_________________________
city
________________________
province
_________________________
postal code
Telephone and Email:
_________________________
area code
_________________________
phone number
_________________________
email address
WIO Participation %:
_________________________
Effective Date (rig release date):
________________________
YYYY - MM - DD
Entity ID (IOGC USE ONLY):
________________________
Royalty Payor #2
Royalty Working Interest Owner:
________________________
company name
_________________________
company code
Address:
_________________________
street
_________________________
city
________________________
province
_________________________
postal code
Telephone and Email:
_________________________
area code
_________________________
phone number
_________________________
email address
WIO Participation %:
_________________________
Effective Date (rig release date):
________________________
YYYY - MM - DD
Entity ID (IOGC USE ONLY):
________________________
Royalty Payor #3
Royalty Working Interest Owner:
________________________
company name
_________________________
company code
Address:
_________________________
street
_________________________
city
________________________
province
_________________________
postal code
Telephone and Email:
_________________________
area code
_________________________
phone number
_________________________
email address
WIO Participation %:
_________________________
Effective Date (rig release date):
________________________
YYYY - MM - DD
Entity ID (IOGC USE ONLY):
________________________
Royalty Payor #4
Royalty Working Interest Owner:
________________________
company name
_________________________
company code
Address:
_________________________
street
_________________________
city
________________________
province
_________________________
postal code
Telephone and Email:
_________________________
area code
_________________________
phone number
_________________________
email address
WIO Participation %:
_________________________
Effective Date (rig release date):
________________________
YYYY - MM - DD
Entity ID (IOGC USE ONLY):
________________________
C - Contact Information
SIGNATURE ________________________
CONTACT PERSON ________________________
TELEPHONE ________________________
EMAIL ADDRESS ________________________
FAX ________________________
(IOGC USE ONLY)
YYYY - MM - DD
Important Information:
Submit via at email or via fax at (403) 292-5618 (ph: (403) 292-6026).
THIS FORM NEEDS TO BE FILED AND A NEW ROYALTY ENTITY NEEDS TO BE ASSIGNED PRIOR TO SUBMISSION OF ROYALTY DATA TO IOGC. IF THIS FORM IS NOT RETURNED WITHIN 10 DAYS, THE GRANTEE WILL ASSUME 100% RESPONSIBILITY FOR THE WELL.