Directive 065 - Energy Resources Conservation Board

Resources Applications - Schedule 1
Applicant General Information
DAY MONTH YEAR APPLICATION #
APPLICANT'S FILE NUMBER
The applicant certifies that the information provided here and in all supporting documentation is correct and in
accordance with all regulatory requirements or as directed by the Energy Resources Conservation Board.
SUBMISSION STATUS SUBMISSION ID CREATION DATE
1. APPLICANT INFORMATION
COMPANY NAME BA CODE
CONTACT NAME
TELEPHONE FAX
E-MAIL
MAILING ADDRESS
2. APPLICATION TYPE
(For Electronic Submission purposes, Resources Applications only accepts one application type per submission)
APPLICATION DESCRIPTION
3. LOCATION (Minimum input Twp/Rg/Mer)
LE Lsd Sec Twp Rge Mer ES LE Lsd Sec Twp Rge Mer ES
4. FIELD AND POOL LIST
Field Name Pool Name
- -
1.
2.
2a.
3.
5. OWNERSHIP AND NOTIFICATION INFORMATION
What is the ownership basis on which you make this application?
Has notification been conducted in accordance with the requirements for this application?
If no, do you need ERCB assistance to complete the notification requirements? Please explain. Yes
Are there outstanding concerns? Yes (please explain)
W
W
W
W
W
W
W
W
W
W
Yes No
No
Yes No