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Arizona State Mine Inspector

1700 W. Washington Street, Suite 403 Phoenix, AZ 85007 602-542-5971 Office 602-542-5335 Fax

Company/CO-OP For information on Mine Safety and Health Administration (MSHA) training classes see Arizona State Mine Inspector (ASMI) web site at www.asmi.az.gov or call 602:542-5971. For information on program guidelines, fees, cancellation and refund policies see: E&T Fees & Policies Document. For individual registration or to register multiple participants in a CO-OP class please submit one (1) month in advance or sooner. Fill out all pertinent information, class location requested and number of participants. Please submit a new form for each request. The Education and Training department will contact you with confirmation or for other available class date(s). Request training for:CO-OP Class Individual or multiple registrants in (select location below): Date of class:

Flagstaff Phoenix Tucson Safford / Thatcher

NOTE: CO-OP registrant for Part 48/46 New Miner Inexperienced/Coal (NMI) available upon request. Special guidelines must be met. Contact Frank Rabago, Training Manager for information. Company Information: Name: Contact Person: Address: Mailing Address: City Phone Number MSHA ID #

State Fax Number

Zip Code Email Address STATE ID #

Metal Surface 1-19

Aggregate Underground 20-49

Coal Contractor 50+

Other

Number of Employees

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Type of Training Requested:

Part 48 AR Part 48 AR Part 48 AR Part 46 AR

Annual Refresher Annual Refresher Underground Annual Refresher Coal Annual Refresher

8 Hours 8 Hours 8 Hours 8 Hours 24 Hours 24 Hours

Part 48 NMI New Miner w/detailed Mine Types and Issues Part 46 NMI New Miner w/detailed Mine Types and Issues Basic FA/CPR/BBP - Sessions Available on 3rd day of NMI training

8 Hours

Approved Part 46 Training Plan Submitted to the Arizona State Mine Inspector Office Number of Students Cost

Registration Fees: Training Class

Annual Refresher New Miner - 3 day w/detailed Mine Types and Issues on 2nd day FA/CPR/BBP Sessions available on 3rd day on NMI training Payment must be received 2 weeks prior to the Total Amount Due date of the class. Payment Type

Credit Card:

Make Money Order / Cashier Check / Company Check Payable to: Arizona State Mine Inspector Purchase Order (mail with form) #________________

Invoice

Visa

MasterCard

American Express

Card Number: Expiration Date: Security Code: Name on Credit Card: Cardholder Signature:
Card Holder Authorization: I agree to pay the above total amount according to card issuer agreement.

Cancellation / Refund Policy Payment must be received prior to the start of class. Payment can be made in the form of a money order and/or cashiers check made payable to Arizona State Mine Inspector (ASMI); MasterCard, Visa and American Express also accepted. Cancellations and/or reschedules must be requested in writing 10 days prior to the start of the class. Registrants who fail to cancel will be classified as a no show and will forfeit the entire registration fee. Participants must be present for the entire Annual Refresher (8-hours) and/or New Miner (24-hours) to receive Certificate of Training MSHA Form 5000-23. Please Note: Personal Checks will not be accepted. Page 2 of 3

For Office Use Only Class Date: Registration Information Last Name 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. First Name

Instructor: Class Location Type of Training Required Approximate date of Last Training

Signature

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