Form 55a001 - Application For Certificate Of Registration For Coal Severers And/or Processors Page 2

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55A001 (4-03)
Page 2
Location of Business (Continued from page 1)
Surface Disturbance
Kentucky Department
MSHA
Location
Contract
Mining Permit
of Mines and
Identification
Mine Name
(County)
Miner Name
Number
Minerals File Number
Number
15-
15-
15-
15-
15-
15-
15-
15-
15-
15-
15-
15-
15-
Mail completed application to:
Kentucky Revenue Cabinet
Taxpayer Registration
P.O. Box 299
Frankfort, KY 40602-0299
For additional information, contact the Department of Property Valuation, Division of
Technical Support at (502) 564-8334.

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