Telecommunication Affidavit

Telecommunication Affidavit Department of Mineral Resources Oil and Gas Division S.F.N (08 to 2025)

This affidavit is made to comply with North Dakota Administrative Code Section 43-02-03-88.2.

Field: First and Last Name

Field: Company Name

Field: Company Street Address

Field: City

Field: State

Field: Zip Code

Field: Telephone Number

Field: N.D.I.C Case Number(s)

Field: Date of Testimony

Field: Affiant's Signature

I swear and do hereby affirm under penalty of perjury under North Dakota law, that I presented testimony under oath in the North Dakota Industrial Commission Case(s) referenced above.

Field: State of

Field: County of

Field: Signed and sworn to (or affirmed) before me this

Field: Date

Field: Notary Public

Field: Affix Notary Stamp

Field: Signature of Notary Public or Other Authorized Officer

Field: Commission Expiration Date

This affidavit should be submitted as soon as possible following the hearing. Pursuant to North Dakota Administrative Code Section 43-02-03-88.2: The record of such telecommunication shall not be considered evidence in the case unless said affidavit is received by the commission prior to an order being issued by the commission.

Completed forms can be emailed to caseapps@nd.gov or sent by mail to the Department of Mineral Resources, 600 E Boulevard Ave Dept 474, Bismarck N.D 58505.