Form MO780-0209 "Oil and Gas Commercial Operator's License Application - Geological Survey Program" - Missouri

What Is Form MO780-0209?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MO780-0209 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form MO780-0209 "Oil and Gas Commercial Operator's License Application - Geological Survey Program" - Missouri

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FOR OFFICE USE ONLY
MISSOURI DEPARTMENT OF NATURAL RESOURCES
GEOLOGICAL SURVEY PROGRAM
PROCESED BY
DATE RECEIVED
OIL AND GAS COMMERCIAL OPERATOR’S LICENSE
APPLICATION
CHECK NUMBER
CHECK AMOUNT
LICENSED CALENDAR YEAR LICENSE NUMBER
APPLICATION TYPE
New
Renewal
Information Update Only (Certificate of registration and fee not required)
BUSINESS INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN
OPERATOR LICENSE NUMBER (IF RENEWAL
MISSOURI
OR UPDATE)
MAILING ADDRESS
COUNTY
CITY
STATE
ZIP
PHYSICAL ADDRESS (IF DIFFERENT THAN ABOVE)
PRIMARY PHONE NUMBER WITH AREA CODE
IF A NAME CHANGE OR REORGANIZATION, GIVE NAME OF PREVIOUS ORGANIZATION
OFFICER INFORMATION
PRINCIPAL OFFICER(S) OR PARTNERS
Name
Title
Primary Phone Number with
Email Address
Area Code
EXT.
EXT.
EXT.
CORRESPONDENCE CONTACT INFORMATION (IF DIFFERENT THAN ABOVE)
Name
Title
Primary Phone Number with
Email Address
Area Code
PRIMARY
EXT.
SECONDARY
EXT.
OTHER
EXT.
METHOD OF PAYMENT
AMOUNT DUE
Check or Money Order (Please enclose check, payable to Department of Natural Resources, with submitted form.)
Credit Card (Transaction fee applies.) (Please attach contact information of person authorized to make transaction.)
$250.00
Automated Clearing House (Please attach contact information of person authorized to make transaction.)
CERTIFICATION
I, the undersigned, certify that:
I am authorized by said business to make this report.
The facts stated herein are true, correct and complete to the best of my knowledge.
I understand that after any change occurs as to facts stated in this report as submitted and filed, a supplementary report shall be filed with the
state geologist with respect to such change within thirty (30) calendar days after the effective date of change.
I have read and am in agreement that this business will comply with the statutes, rules and provisions pursuant to Chapter 259, RSMo, and
the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR 50.
PRINT NAME
PRINT COMPANY NAME
SIGNATURE
DATE
FOR OFFICE USE ONLY
APPROVED BY
DATE
SEND COMPLETED FORM ALONG WITH $250 LICENSE FEE BY JANUARY 1 TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES,
MO 780-0209 (2-18)
MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov
FOR OFFICE USE ONLY
MISSOURI DEPARTMENT OF NATURAL RESOURCES
GEOLOGICAL SURVEY PROGRAM
PROCESED BY
DATE RECEIVED
OIL AND GAS COMMERCIAL OPERATOR’S LICENSE
APPLICATION
CHECK NUMBER
CHECK AMOUNT
LICENSED CALENDAR YEAR LICENSE NUMBER
APPLICATION TYPE
New
Renewal
Information Update Only (Certificate of registration and fee not required)
BUSINESS INFORMATION
NAME OF COMPANY, ORGANIZATION, OR INDIVIDUAL THAT DRILLS, MAINTAINS, OPERATES, OR CONTROLS OIL AND GAS WELLS IN
OPERATOR LICENSE NUMBER (IF RENEWAL
MISSOURI
OR UPDATE)
MAILING ADDRESS
COUNTY
CITY
STATE
ZIP
PHYSICAL ADDRESS (IF DIFFERENT THAN ABOVE)
PRIMARY PHONE NUMBER WITH AREA CODE
IF A NAME CHANGE OR REORGANIZATION, GIVE NAME OF PREVIOUS ORGANIZATION
OFFICER INFORMATION
PRINCIPAL OFFICER(S) OR PARTNERS
Name
Title
Primary Phone Number with
Email Address
Area Code
EXT.
EXT.
EXT.
CORRESPONDENCE CONTACT INFORMATION (IF DIFFERENT THAN ABOVE)
Name
Title
Primary Phone Number with
Email Address
Area Code
PRIMARY
EXT.
SECONDARY
EXT.
OTHER
EXT.
METHOD OF PAYMENT
AMOUNT DUE
Check or Money Order (Please enclose check, payable to Department of Natural Resources, with submitted form.)
Credit Card (Transaction fee applies.) (Please attach contact information of person authorized to make transaction.)
$250.00
Automated Clearing House (Please attach contact information of person authorized to make transaction.)
CERTIFICATION
I, the undersigned, certify that:
I am authorized by said business to make this report.
The facts stated herein are true, correct and complete to the best of my knowledge.
I understand that after any change occurs as to facts stated in this report as submitted and filed, a supplementary report shall be filed with the
state geologist with respect to such change within thirty (30) calendar days after the effective date of change.
I have read and am in agreement that this business will comply with the statutes, rules and provisions pursuant to Chapter 259, RSMo, and
the Missouri Code of State Regulations Oil and Gas Council Rules 10 CSR 50.
PRINT NAME
PRINT COMPANY NAME
SIGNATURE
DATE
FOR OFFICE USE ONLY
APPROVED BY
DATE
SEND COMPLETED FORM ALONG WITH $250 LICENSE FEE BY JANUARY 1 TO: MISSOURI DEPARTMENT OF NATURAL RESOURCES,
MO 780-0209 (2-18)
MISSOURI GEOLOGICAL SURVEY, GEOLOGIC RESOURCES SECTION, PO BOX 250, ROLLA, MO 65402
PHONE: 573-368-2100 FAX: 573-368-2111 EMAIL:
oilandgas@dnr.mo.gov