OFFICIAL ELECTRICAL EXPERIENCE DOCUMENT

← Back to document page

REVISED 05-2013 Attach recent photograph or Copy of Driver s Liceense Cert. No. Date of Issue Certifiying Officer State of West Virginia Office of Miners ' Health, Safety and Training 7 Players Club Suite 2 Charleston, West Virginia 25311-1626 Phone: 304-558-1425 Fax: 304-558-1282 OFFICIAL ELECTRICAL EXPERIENCE DOCUMENT Company Phone Number Mine Phone Number Company OFFICIAL Signature Title APPLICANT INFORMATION Name SSN Address Phone Number Underground Miner s certificate Number Surface Miner s certificate Number EXPERIENCE INFORMATION ( ) Reciprocity ( ) In-State EXPERIENCE ( ) Out-of -State EXPERIENCE Apprentice Card Date Issued MIIN Number Scheduled work days during Apprenticeship period Days worked during Apprenticeship period Amount of ELECTRICAL EXPERIENCE (Low & Medium Voltage) Amount of ELECTRICAL EXPERIENCE (High Voltage) Number of hours of classroom training Instructor Signature Date ( )

OFFICIAL ELECTRICAL EXPERIENCE DOCUMENT. ... Underground Miner’s Certificate Number Surface Miner’s Certificate Number. EXPERIENCE INFORMATION ( ) Reciprocity ( ) In-State Experience ( ) Out-of-State Experience. Apprentice Card Date Issued MIIN Number Scheduled work days during Apprenticeship period Days worked during Apprenticeship period ...

  Certificate, Work, Experience