msha training registration form
MSHA TRAINING REGISTRATION FORM
THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT DEPARTMENT OF LABOR STANDARDS
Please return this registration information no later than December 15, 2017. Mail to: MSHA Program Massachusetts Department of Labor Standards 37 Shattuck Street Lawrence, MA 01843 or e-mail to: [email protected], or Fax to 978-687-0013 Company name
Mailing address Contact person Phone number Email address
Is your company: a Mine OR a Contractor? If your company is a contractor, do you have: 6 or more OR 5 or less employees conducting work at mines? If your company is a mine: What is the Mine location:
MSHA I.D.:
Are there: 6 or more OR 5 or less miners working at this mine? DLS may be hosting a FREE Miner Appreciation and Safety Summit in 2018. This would include presentations on the latest technologies and safety best practices. It would be free to attend, and food would be served. This would be a special event and would not fulfill the annual refresher requirement. Would employees from your company be interested in attending an event like this: Yes No If yes, what topic would you want to hear about:
Please submit a separate registration form for each different Mine location. List all employees you are registering for training in the table below. This table continues on the back. Registration will be confirmed by email, a reminder email will be sent one week before class. Foul weather policy: Please check Mass.gov/dols for possible cancellations. As a general rule, when training is at a school if the facility cancels classes the MSHA class will also be cancelled. If classes at the school are delayed until 10am the MSHA class will take place. If there is a delay past 10am the MSHA class will be cancelled.
Name of Worker
Title
Class Location
Class Date
THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT DEPARTMENT OF LABOR STANDARDS
Please return this registration information no later than December 15, 2017. Mail to: MSHA Program Massachusetts Department of Labor Standards 37 Shattuck Street Lawrence, MA 01843 or e-mail to: [email protected], or Fax to 978-687-0013 Company name
Mailing address Contact person Phone number Email address
Is your company: a Mine OR a Contractor? If your company is a contractor, do you have: 6 or more OR 5 or less employees conducting work at mines? If your company is a mine: What is the Mine location:
MSHA I.D.:
Are there: 6 or more OR 5 or less miners working at this mine? DLS may be hosting a FREE Miner Appreciation and Safety Summit in 2018. This would include presentations on the latest technologies and safety best practices. It would be free to attend, and food would be served. This would be a special event and would not fulfill the annual refresher requirement. Would employees from your company be interested in attending an event like this: Yes No If yes, what topic would you want to hear about:
Please submit a separate registration form for each different Mine location. List all employees you are registering for training in the table below. This table continues on the back. Registration will be confirmed by email, a reminder email will be sent one week before class. Foul weather policy: Please check Mass.gov/dols for possible cancellations. As a general rule, when training is at a school if the facility cancels classes the MSHA class will also be cancelled. If classes at the school are delayed until 10am the MSHA class will take place. If there is a delay past 10am the MSHA class will be cancelled.
Name of Worker
Title
Class Location
Class Date
