APPLICATION FOR SPECIAL USE LEASE - Wyoming State Lands

(Bd. Apprvd. 9-3-1998)
Lease No. _______________
County _______________
STATE OF WYOMING
BOARD OF LAND COMMISSIONERS
APPLICATION FOR SPECIAL USE LEASE
TO: THE BOARD OF LAND COMMISSIONERS, Herschler Building, Cheyenne, Wyoming
82002-0600. Pursuant to the provisions of W.S. 36-5-101 et. seq., the undersigned hereby makes
application to lease the lands described for the purpose and term requested:
1) Lease Applicant: _________________________________________________________
(Fill in as you want name shown on lease)
Address:
Phone:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
(If you are the current lessee and are requesting a name change, you will be required to
complete a lease assignment form in accordance with Wyoming Statutes 36-5-105).
a) If the applicant is a limited partnership or corporation, is it qualified under the laws
of the State of Wyoming to do business therein? _______. Where is your principal
place of business? _________________________________________.
b) If the applicant is an individual, are you a citizen of the United States? _____. (If
not, have you declared your intention to become a citizen? _______.)
2) Legal Description of Lands Applied For:
3) Description of the Proposed Use:

4) Describe the type and value of the improvements you intend to place on the land:
5) Describe the type and value of existing improvements on the land and list the owner(s) of
those improvements:
6) Will the proposed use result in loss of forage or timber production, unusable or inaccessible
land or water, surface disturbance, or damage to crops, timber, or improvements? Yes
_______. No _______. If yes, describe:
7) Requested lease term (maximum of 25 years): From ______________ To _____________
(Date) (Date)
8) Annual Lease Rental Offer and Fees:
Annual Lease Rental Offer=
Lease Application Filing Fee= $25.00 (non-refundable)
Total Remittance =
___________
(Application must be signed by all applicants. If a corporation, application must be signed by an
authorized officer.)
Dated _____________
(Sign) X _________________________ X _____________________
(Sign) X _________________________ X _____________________
RENTAL NOTICES TO BE MAILED TO:
____________________________________
(NAME)
____________________________________
(ADDRESS)
____________________________________
____________________________________
____________________________________
(PHONE)