Mine Safety and Health Administration
Request for MSHA Individual Identification Number (MIIN) MSHA FORM 5000-46
This form is affected by the Privacy Act of 1974.
Approved for use through 11/30/2023, 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 .5
milligrams per cubic meter of air under 30 CFR 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 c
ollection 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, Office of Standards, Regulations and Variances, 201 12th Street South, Suite 401, Arlington, Virginia 22202-5450. 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:
Fir
Name
st Middle Last Suffix
Initial Name
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:
ZZMSHA-EPDQC@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:
MSHA Form 5000-46, revised Aug. 2015 (mailing address)
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