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:
*
Format: (000) 000-0000.
Primary Contact:
*
Bidder intends to operate the business with which this bid is concerned as
*
Sole Proprietorship
Partnership
Corporation
Joint Venture
Other (explaination required)
Other: Explain
If Sole Proprietorship Please complete
Name in full
Address
Email
*
example@example.com
Birth date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of birth
Social Security number
If Partnership Please complete
Date of organization
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Partnership type
Please Select
General partnership
Limited partnership
State of partnership recorded?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Book
Page
County
Has the partnership ever done business in West Virginia?
Yes
No
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?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where incorporated?
Is the corporation authorized to do business in West Virginia?
Yes
No
If yes, as of what date?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
The corporation is held
Publicly
Privately
If publicly held, how and where is the stock traded?
If a joint venture, answer the following
Date of organization
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Joint venture agreement recorded
Yes
No
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
Have you ever declared bankruptcy?
*
Yes
No
If yes, date, court jurisdiction, amount of liabilities, and amount of assets.
Have you or any principals of the business entity, as applicable, ever been convicted of a felony?
*
Yes
No
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.
*
Are you currently paid up-to-date on your local, state and federal taxes?
*
Yes
No
Are you currently paid up-to-date on West Virginia Workers Compensation?
*
Yes
No
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
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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.
Submit
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