Form IDLOGD 0019 Designation of Agent Form - Idaho

Form IDLOGD0019 is a Idaho Department of Lands form also known as the "Designation Of Agent Form". The latest edition of the form was released in August 1, 2017 and is available for digital filing.

Download an up-to-date Form IDLOGD0019 in PDF-format down below or look it up on the Idaho Department of Lands Forms website.

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IDAHO OIL AND GAS CONSERVATION COMMISSION
DESIGNATION OF AGENT FORM
Any party acting as an agent of an owner(s) of the lease or well shall have a valid Designation of Agent form on file with the
Commission prior to the start of operations. A Designation of Agent(s) will be accepted as authority of the agent to fulfill
the obligations of the owner and to sign any required papers or reports. All authorized orders or notices given by the
Department to the agent shall be deemed service of such orders or notices upon the owner and the lessee. This
designation shall remain in effect until written notice is provided by the owner to terminate the agent or representative, and
the designation of a new agent(s) shall be immediately made. All changes of address must be immediately reported in
writing to the Department.
AGENT COMPANY NAME:
Contact Name:
Contact Title:
Signature:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
ADD AGENT
REMOVE AGENT
(check one)
AGENT COMPANY NAME:
Contact Name:
Contact Title:
Signature:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
ADD AGENT
REMOVE AGENT
(check one)
AGENT COMPANY NAME:
Contact Name:
Contact Title:
Signature:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
ADD AGENT
REMOVE AGENT
(check one)
Pursuant to the Rules Governing Conservation of Oil and Natural Gas in the State of Idaho (IDAPA 20.07.02.033), the
below-signed owner or operator who is conducting oil and gas operations in the State of Idaho, does hereby designate or
remove the above-listed Agent Company and/or representative(s) as authorized to sign on behalf of the owner or operator.
Owner or Operator Company Name:
Print Authorizing Name:
Authorizing Title (must be an officer):
Authorizing Signature:
Approval Date:
Page 1 of 2
IDLOGD0019. (8/17)
IDAHO OIL AND GAS CONSERVATION COMMISSION
DESIGNATION OF AGENT FORM
Any party acting as an agent of an owner(s) of the lease or well shall have a valid Designation of Agent form on file with the
Commission prior to the start of operations. A Designation of Agent(s) will be accepted as authority of the agent to fulfill
the obligations of the owner and to sign any required papers or reports. All authorized orders or notices given by the
Department to the agent shall be deemed service of such orders or notices upon the owner and the lessee. This
designation shall remain in effect until written notice is provided by the owner to terminate the agent or representative, and
the designation of a new agent(s) shall be immediately made. All changes of address must be immediately reported in
writing to the Department.
AGENT COMPANY NAME:
Contact Name:
Contact Title:
Signature:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
ADD AGENT
REMOVE AGENT
(check one)
AGENT COMPANY NAME:
Contact Name:
Contact Title:
Signature:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
ADD AGENT
REMOVE AGENT
(check one)
AGENT COMPANY NAME:
Contact Name:
Contact Title:
Signature:
Address:
City:
State:
Zip Code:
Telephone:
Email Address:
ADD AGENT
REMOVE AGENT
(check one)
Pursuant to the Rules Governing Conservation of Oil and Natural Gas in the State of Idaho (IDAPA 20.07.02.033), the
below-signed owner or operator who is conducting oil and gas operations in the State of Idaho, does hereby designate or
remove the above-listed Agent Company and/or representative(s) as authorized to sign on behalf of the owner or operator.
Owner or Operator Company Name:
Print Authorizing Name:
Authorizing Title (must be an officer):
Authorizing Signature:
Approval Date:
Page 1 of 2
IDLOGD0019. (8/17)
IDAHO OIL AND GAS CONSERVATION COMMISSION
DESIGNATION OF AGENT FORM
DESIGNATION OF AGENT
FORM INSTRUCTIONS
Introduction
Any person may be designated to act as an agent of a registered and bonded owner or operator of a lease or well, provided
the operator has filed a Designation of Agent Form bestowing that authority unto that person (see IDAPA 20.07.02.033).
Designated person(s) have signature authority on Commission required reports or logs, and will be a point of contact for
any discrepancies on submitted documents or logs. The designation remains in effect until written notice is provided by the
owner or operator to terminate the authority of that designated agent or representative. It is the responsibility of the owner
or operator to maintain their agent lists by submitting any deletions of designated agents or changes in designated agent’s
information on a new Designation of Agent Form.
Instructions for completing this form are as follows:
Section 1:
Agent Information section designates agents other than employees of the registered and bonded owner or
operator. This section does not need to be completed for authorizing employees of the permittee of record. Complete
this section when authorizing persons who are employed by an agent company. Please note that the Agent can either
be added or removed. One or more Agents can be added or removed on each form. Complete additional forms as
needed.
Section 2:
Owner or Operator Information section provides information on the permittee of record and an authorizing
corporate officer for the Designation of Agent. Fill in full name of the permittee of record (same as owner or
operator), the printed name of the corporate officer from the permittee of record, the individual’s title, and their
signature. The approval date is the effective date of Designation (MM/DD/YYYY).
Page 2 of 2
IDLOGD0019. (8/17)

Download Form IDLOGD 0019 Designation of Agent Form - Idaho

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