Adobe FormsCentral

West Virginia Mineral Development

Bid Questionnaire Form

Note: All information requested in this form must be provided by the bidder and must be submitted with the bid. Statements must be complete and accurate. Omission, inaccuracy or misstatement will be cause for the rejection of the bid.

Name of bidder exactly as it appears on the bid proposal and as it would appear on a license/lease agreement*

Address of bidder for purposes of notice or other communication relating to the bid proposal*

Telephone number of bidder:*

Primary Contact:*

Other: Explain

If Sole Proprietorship Please complete

Name in full

Address

Email*

Birth date

Place of birth

Social Security number

If Partnership Please complete

Date of organization

Partnership type

YesNo

Date

Book

Page

County

YesNo

When / Where / For what purpose

Name, address and partnership share of each partner

Name

Address

Share

Furnish the birthdates, place of birth and social security number for each person shown above

If a corporation, answer the following:

When incorporated?

Where incorporated?

YesNo

If yes, as of what date?

PubliclyPrivately

If publicly held, how and where is the stock traded?

If a joint venture, answer the following

Date of organization

YesNo

Name and Address of each joint venture

Name

Address

Furnish the birthdate, place of birth and social security number for each person shown under above item

YesNo

If yes, date, court jurisdiction, amount of liabilities, and amount of assets.

YesNo

If Yes please state date, court location and details of conviction.

Enumerate in detail the duration and extent of your exploration and production experience, with special emphasis on experience with business related to the development, operation, and production of the coal, oil gas, sand gravel and any other minerals.*

Identify whether your company owns or controls, by leasehold or otherwise, any properties surrounding or nearby the targeted property. If yes, please describe those properties and/or furnish maps or plats of those properties to the Division of Natural Resources.*

Enumerate in detail the pertinent experience of the key persons who will be directly involved in your development and production of the state’s coal, oil, gas, sand, gravel and any other minerals.*

Provide any other information that may be helpful to the Division of Natural Resources in evaluating this bid.*

YesNo

Targeted Property

Indicate property on which there is an interest.*

County:*

Tax District*

Parcel Number*

Gross Acreage*

If it’s under the Ohio River, please provide the applicable mile post.

Upload tax map if available

Select File

By submission of this bid, the bidder acknowledges and agrees that the Division of Natural Resources has the right to make any inquiry or investigation it deems appropriate to substantiate or supplement information contained in this questionnaire, and authorizes the release to the Division of Natural Resources of any information sought in such inquiry or investigation.