Instructions for Completing the MSHA Individual Identification Number (MIIN) This information is intended only for the individual named in this document. If you are not the intended recipient, you are notified that use, disclosure, or distribution of the information is strictly prohibited and may be subject to criminal sanctions. If you received this information in error, please notify the Mine Safety and Health Administration Qualification and Certification Unit, P.O. Box 25367, Denver, CO 80225, locally in Colorado (303) 231-5472, toll free (800) 579-2647, Fax (303) 231-5474, E-Mail to: ZZMSHA-EPDQC@DOL.GOV Applying for and receiving a MIIN does not change your immigration status or your right to work in the United States. Please print legibly Personal Identification number (REQUIRED) This will be your Social Security Number (SSN), Canadian Social Insurance Number (CSIN) for Canadian citizens working in the United States, or Individual Tax Identification Number (ITIN), foreign nationals working in the United States that do not have an SSN. Without the Personal Identification Number MSHA will not be able to move your current qualifications or approvals to your new MIIN number or issue a MIIN number to you. Legal Name (REQUIRED) First Name is required Middle Initial Last Name is required Suffix (Jr., Sr., II etc.) Mailing Address (REQUIRED) This is the address where you would like to have your MIIN information mailed to. Questions for Miner Validation – (REQUIRED) Check one question only. Your selected question will be asked by MSHA personnel to validate that we are speaking to the actual MIIN holder when you call to request your records or to make changes. You must remember your selected question. Answer to question – (REQUIRED) Supply a one word answer to the question you have selected. MSHA will ask the question you have selected and you will supply the answer to the question. You must remember your selected answer. Signature - (REQUIRED) Date - (REQUIRED) Return Form to: Mine Safety and Health Administration Qualification and Certification Unit P.O. Box 25367, DFC Denver, CO 80225 Fax: 303-231-5474 MSHA Form 5000-46 January 2008 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com U.S. Department of Labor Mine Safety and Health Administration Request for MSHA Individual Identification Number (MIIN) This form is affected by the Privacy Act of 1974 Approved for use through January 31, 2011, OMB Control Number 1219-0143 The Mine Safety and Health Administration (MSHA) will issue a MSHA Individual Identification Number (MIIN) to persons seeking qualifications and/or certification under 30 CFR Part 48, Part 70, Part 71, Part 75.00, 75.153, 75.155, Part 77.100, 77.103, 77.104, 77.105 and Part 90. Completion of this form is mandatory, as this number will be used for all applications for certifications or qualifications and will also cover any prior certification or qualification issued by MSHA. This number will be used for all occurrences of training or applications to MSHA that are submitted by the mining operator, instructor, State, or person applying to be an MSHA approved instructor. Once MSHA receives this request, a MIIN will be mailed to the address provided below. This number must be used when applying for or receiving qualifications or certifications and when contacting MSHA for questions or corrections of information. This number will also be used to identify miners who have exercised their option to work in areas of a mine with respirable dust concentration at or below 1.0 milligrams per cubic meter of air under 30CFR Part 90. Information on this form will be kept confidential to the extent allowed by the law. Instructions for this form contain further information on the need and use of this form. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data need, and completing and reviewing the collection of information. Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety and Health Administration, U.S. Department of Labor, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Please read the instructions before entering information on the form Please print Personal Identification Number Type of ID SSN CSIN ITIN Legal Name: First Name Middle Initial Last Name Suffix Mailing Address: 1st Street 2nd Street City State Zip Code Country Questions will be used for personal validation. Select one question that MSHA may use to validate that we are speaking to the actual MIIN holder: Select check box for question to be answered, use a single word answer for selected question 1. What is your grandfather’s first name? 2. What is the name of the city/town you were born in? Answer 3. What was the model of your first vehicle? 4. What is the name of your favorite sports team? 5. What was your first pet's name? False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL91-173 as amended by PL 95-164) Signature Date For questions on this application, please contact the Q & C Unit (303) 231-5472 or (800) 579-2647, Fax (303) 231-5474, E-Mail to: ZZMSHAEPDQC@DOL.GOV Return Form to: Mine Safety and Health Administration Qualification and Certification Unit P.O. Box 25367, DFC Denver, CO 80225 MSHA Use Only: American LegalNet, Inc. www.FormsWorkflow.com MSHA Form 5000-46 January 2008 Page 2 of 2