OFFICIAL ELECTRICAL EXPERIENCE DOCUMENT

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 ( )

REVISED 05-2013 Attach recent photographor . Copy of Driver’s Liceense Cert. No. Date of Issue Certifiying Officer

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