Fillable 2019 MSHA Registration Form

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2019 MSHA Registration Form

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The 2019 MSHA Registration Form form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Please return this registraon informaon no later than December 15, 2018.
Mail to: MSHA Program
MassachusesDepartmentofLaborStandards
37ShauckStreet
Lawrence,MA01843
or e-mail to: susan.humphreys@state.ma.us,orFaxto978-687-0013
Companyname
Mailingaddress
Contactperson
Phonenumber
Emailaddress
Isyourcompany:
aMineOR aContractor?
If your company is a contractor,doyouhave:
6ormoreOR 5orlessemployeesconducngworkatmines?
If your company is a mine:
WhatistheMinelocaon: MSHAI.D.:
Are there: 6ormoreOR 5orlessminersworkingatthismine?
Please submit a separate registraon form for each dierent Mine locaon.
List all employees you are registering for training in the table below. This table connues on
the back. Registraon will be conrmed by email, a reminder email will be sent one week
before class.
Foul weather policy:PleasecheckMass.gov/dolsforpossiblecancellaons.Asageneralrule,
whentrainingisataschoolifthefacilitycancelsclassestheMSHAclasswillalsobecancelled.
Ifclassesattheschoolaredelayedunl10amtheMSHAclasswilltakeplace.Ifthereisa
delaypast10amtheMSHAclasswillbecancelled.
MSHA TRAINING
REGISTRATION FORM
T
HE
C
OMMONWEALTH OF
M
ASSACHUSETTS
E
XECUTIVE
O
FFICE OF
L
ABOR AND
W
ORKFORCE
D
EVELOPMENT
D
EPARTMENT OF
L
ABOR
S
TANDARDS
NameofWorker Title ClassLocaon ClassDate
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2019 MSHA Registration Form

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Completed 15 May 2020

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