Education And Training Form - Arizona State Mine Inspector

Download a blank fillable Education And Training Form - Arizona State Mine Inspector in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Education And Training Form - Arizona State Mine Inspector with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

EDUCATION AND TRAINING FORM

Once you have filled out the form please fax it to (602) 542-5335 or

mail it to the address on the form with a money order or cashier’s

check made out to the: Arizona State Mine Inspector.

NOTE: The Education and Training fees are dependent on the

Federal MSHA grant allocation. Current fee rates cannot be

guaranteed for future classes.

Arizona State Mine Inspector

1700 W. Washington St., Suite 403

PLEASE TYPE IN ALL DATA

Phoenix, AZ 85007

(602) 542-5971

Student Information:

Name:

Address

City

State

Zip Code:

Email:

TRAINING CLASS (Select one):

Registration Fees:

Annual Refresher

- 1 day class (8 hours)

$15.00

Annual Refresher

$ 0.00

New Miner

- 3 day class (24hours)

$30.00

New Miner – 3 day

$ 0.00

(Detailed Mine Types and Issues

with Detailed Mine Types and Issues

FA/CPR/BBP

- 1 day class (8hours)

$10.00

FA/CPR.BBP

$ 0.00

Sessions Available on 3

day of NMI training.

Total Due

$ 0.00

MSHA Certification Type:

Part 48

Part 46

Training Address:

Class Dates:_______________________________________

Location of training class (select one):

Flagstaff

Phoenix

Tucson

Other___________

ATTENTION: All State Agencies/Buildings will be enforcing the following for all MSHA training classes;

Pursuant to A.R.S. § 13-3102, all participants are hereby notified that they prohibited from entering or attending this training program carrying a weapon of

any kind. If in possession of a weapon, when attempting to enter the building for participation in such program you may be denied access to participation

in the program while in possession of such weapon.

Payment

Company Name:

Make Money Order / Cashier Check Payable to:

Mailing Address:

Arizona State Mine Inspector

City:

State:

Zip Code:

Credit Card

Phone Number:

Visa