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Extension Agreement Application Form

Company Name

Company Address

City

State

Postal Code

Phone

Mobile Phone (Optional)

Name and Title

Email Address

Spacing Unit Description

Well Name

Well Operator

Lease Number(s)

Lessee

Expected spud

Reason for Request

Upload pdf File (Optional)

1707 North 9th Street | Bismarck, ND 58506-5523 | Telephone: (701)328-2800 | Fax: (701)328-3650