OFFICIAL ELECTRICAL EXPERIENCE DOCUMENT

1 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)

2 Number of hours of classroom training Instructor Signature Date ( ) ELECTRICAL Engineering degree and six months EXPERIENCE (ATTACH COPY of DEGREE) ( ) Previous ELECTRICAL Certifications: Underground _____ Surface _____ Prep Plant _____ ( ) Three or more years of ELECTRICAL EXPERIENCE (ATTACH LETTER(s) FROM COMPANY OFFICIAL ) I hereby certify that the above named applicant has demonstrated sufficient knowledge in the areas applicable for ELECTRICAL certification. Signature Certified Electrician Certification Number 22A-1-21 (d) Whoever knowingly makes any false statements, representation, or certification in any application, record, report, plan or other DOCUMENT filed or required to be maintained pursuant to this law or any order or decision issued under this shall be guilty of a misdemeanor, an upon conviction thereof, shall be fined not more than $5, or imprisoned in the county jail not more than 6 months or both fined and imprisoned.

3 Signature of Applicant Date