+---------+-------------------------------------------------+---------+
| !       | **U.S. DEPARTMENT OF THE INTERIOR**             | !       |
| [](medi |                                                 | [](medi |
| a/image | **OFFICE OF SURFACE MINING**                    | a/image |
| 1.png){ |                                                 | 2.png){ |
| width=" | **APPLICATION FOR BLASTER CERTIFICATION**       | width=" |
| 0.87430 |                                                 | 0.90972 |
| 5555555 | **IN FEDERAL PROGRAM STATES AND ON INDIAN       | 2222222 |
| 5556in" | LANDS**                                         | 2222in" |
| he      |                                                 | he      |
| ight="0 | **OSM Form 74**                                 | ight="0 |
| .777777 |                                                 | .795138 |
| 7777777 |                                                 | 8888888 |
| 778in"} |                                                 | 888in"} |
+---------+-------------------------------------------------+---------+

+----------------------------------+-----------------------------------+
| **GENERAL INSTRUCTIONS**         | **ITEM 15. Employment History and |
|                                  | Blasting Experience.**            |
| 1\. Furnish all requested        |                                   |
| information. Information         | > Start with your most recent job |
| provided on this application     | > in blasting and work back in    |
| will strongly influence OSM's    | > time (month and year). Include  |
| decision to grant an applicant   | > additional pages, if needed. If |
| blaster certification.           | > there was a break in employment |
|                                  | > with one company, treat each    |
| 2\. Use additional sheets if     | > period of employment as a       |
| more space is needed to complete | > separate job. Include the       |
| any of the items. Indicate at    | > company name and address. List  |
| the top of each additional sheet | > your immediate supervisor and   |
| your full name, social security  | > his/her work telephone number,  |
| number, and item number. Insert  | > if known. If you do not know    |
| the sheet between the pages of   | > his/her work number, give the   |
| this application.                | > phone number of the company     |
|                                  | > where your supervisor may be    |
| 3\. Be sure to include with your | > located. Show your full title   |
| application all other forms      | > and provide a full description  |
| required (for example, see the   | > of your work.                   |
| statement required under Item 16 |                                   |
| of "Instructions for Specific    | **ITEM 16. Education and          |
| Items").                         | Training.**                       |
|                                  |                                   |
| 4\. If this application is for a | Section A - Complete the          |
| replacement or renewal           | educational level background      |
| certificate, answer Items 1 thru | information.                      |
| 13, 15, 17, and 19 only.         |                                   |
|                                  | Section B - List any type of      |
| 5\. Any experience which you     | formal classroom and on-the-job   |
| want counted as on-the-job       | training you have received.       |
| training must be accompanied by  |                                   |
| a statement describing the       | Section C - Describe any          |
| training and signed by the       | additional training related to    |
| supervisor.                      | blasting that you have had, such  |
|                                  | as, training in mining equipment  |
| **INSTRUCTIONS TO SPECIFIC       | operations, mining methods, other |
| ITEMS**                          | related equipment operations,     |
|                                  | etc.                              |
| **ITEMS 1 THRU 12.               |                                   |
| Self-Explanatory.**              | Include training vouchers,        |
|                                  | certificates, or other proof of   |
| **ITEM 13. Type of Certificate   | satisfactory completion of        |
| You Are Applying For.**          | training courses and seminars     |
|                                  | listed in Items 16B and 16C.      |
| a\. Check "Issue" if this is an  |                                   |
| application for your first       | **ITEM 17. Blaster Certification  |
| certificate.                     | History.**                        |
|                                  |                                   |
| b\. Check "Renewal" if this      | Section A - Indicate your present |
| application is for a             | status and include the type of    |
| certification that is being      | blaster licenses/certification    |
| renewed; one that was issued     | and the number.                   |
| approximately three years ago.   |                                   |
|                                  | Section B - Describe any other    |
| c\. Check "Reissue" if this      | blaster or blaster related        |
| application is for a             | licenses or certificates you have |
| certification that follows a     | received from any sources,        |
| prior certification (Not a       | including States and private      |
| renewal) that was issued six     | firms.                            |
| years ago.                       |                                   |
|                                  | Section C - Describe fully any    |
| d\. Check "Replacement" if your  | instance where your licenses or   |
| original certificate has been    | certifications have been revoked  |
| lost and you are applying for a  | or any disciplinary action had    |
| replacement.                     | been taken against you involving  |
|                                  | your blaster license or           |
| e\. Check "Reciprocity" if you   | certificate. Describe the         |
| are a certified blaster holding  | circumstances and the outcome of  |
| a current blaster certificate    | each case. Include any civil or   |
| under an OSM approved State      | criminal charges that may have    |
| program.                         | arisen out of these actions and   |
|                                  | the resolution to those charges.  |
| (INCLUDE CHECK OR MONEY ORDER    |                                   |
| MADE PAYABLE TO: OFFICE OF       | **ITEM 18. Law Violation          |
| SURFACE MINING)                  | History.**                        |
|                                  |                                   |
| **ITEM 14. Examination Date.**   | If your response is "yes" to      |
|                                  | either Items 18A or 18B, describe |
| OSM will periodically publish a  | fully the circumstances of the    |
| list of examination dates and    | charges and how the issue was     |
| locations. If you do not know    | resolved.                         |
| when and where examinations will |                                   |
| be given, contact your nearest   | **ITEM 19. Affirmation.**         |
| OSM Field Office.                |                                   |
|                                  | Date and sign in ink.             |
+----------------------------------+-----------------------------------+

**FILL OUT ENTIRE FORM. TYPE OR PRINT ALL INFORMATION IN INK.**

+----------------------+------------+----------------+-----------------+
| **U.S. DEPARTMENT OF |            |                |                 |
| THE INTERIOR**       |            |                |                 |
|                      |            |                |                 |
| **OFFICE OF SURFACE  |            |                |                 |
| MINING**             |            |                |                 |
|                      |            |                |                 |
| **APPLICATION FOR    |            |                |                 |
| BLASTER              |            |                |                 |
| CERTIFICATION**      |            |                |                 |
|                      |            |                |                 |
| **IN FEDERAL PROGRAM |            |                |                 |
| STATES AND ON INDIAN |            |                |                 |
| LANDS**              |            |                |                 |
|                      |            |                |                 |
| OMB No. 1029-0083    |            |                |                 |
|                      |            |                |                 |
| Expires: 12/31/2011  |            |                |                 |
+----------------------+------------+----------------+-----------------+
| **Please Read        |            |                |                 |
| Instructions Before  |            |                |                 |
| Completing**         |            |                |                 |
+----------------------+------------+----------------+-----------------+
| **1.** Name (last,   |            |                | DO NOT WRITE IN |
| first, middle        |            |                | THIS BLOCK (for |
| initial)             |            |                | OSM use only)   |
+----------------------+------------+----------------+-----------------+
| 2\. Mailing Address  |            |                | Date            |
| (Street, Route, P.O. |            |                | Application     |
| Box)                 |            |                | Received        |
+----------------------+------------+----------------+-----------------+
| 3\. City State Zip   |            |                | Application     |
|                      |            |                | Complete        |
|                      |            |                |                 |
|                      |            |                | ⁭Yes ⁭ No         |
+----------------------+------------+----------------+-----------------+
| 4\. Home Telephone   | 5\. Office |                | Amount Fee      |
| Number (include area | Telephone  |                | Received        |
| code)                | Number     |                |                 |
|                      | (include   |                | \$              |
|                      | area code) |                |                 |
+----------------------+------------+----------------+-----------------+
| 6\. Date of Birth    | 7\. Social |                | Examination     |
| (month, day, year)   | Security   |                | Date            |
|                      | Number     |                |                 |
+----------------------+------------+----------------+-----------------+
| 8\. Sex              | 9\. Color  |                | Examination     |
|                      | of Hair    |                | Rating          |
| ⁭Male ⁭ Female         |            |                |                 |
+----------------------+------------+----------------+-----------------+
| 10\. Height          | 11\.       | 12\. Color of  | Date            |
|                      | Weight     | Eyes           | Certificate     |
| feet inches          |            |                | Issued          |
|                      | pounds     |                |                 |
+----------------------+------------+----------------+-----------------+
| 13\. TYPE OF         |            |                |                 |
| CERTIFICATE (FEE IS  |            |                |                 |
| SHOWN IN             |            |                |                 |
| PARENTHESES)         |            |                |                 |
+----------------------+------------+----------------+-----------------+
| ⁭ISSUE (\$122.00) ⁭    |            |                |                 |
| REISSUE (\$122.00) ⁭  |            |                |                 |
| RECIPROCITY          |            |                |                 |
| (\$61.00)            |            |                |                 |
|                      |            |                |                 |
| ⁭RENEWAL (\$61.00) ⁭   |            |                |                 |
| REPLACEMENT          |            |                |                 |
| (\$28.00)            |            |                |                 |
+----------------------+------------+----------------+-----------------+
| 14\. If this         |            |                |                 |
| application is for   |            |                |                 |
| an ISSUE or REISSUE  |            |                |                 |
| certification,       |            |                |                 |
| indicate date and    |            |                |                 |
| location, if known,  |            |                |                 |
| of examination you   |            |                |                 |
| wish to take.        |            |                |                 |
|                      |            |                |                 |
| > Date: Location:    |            |                |                 |
| > [.]{.underline}    |            |                |                 |
+----------------------+------------+----------------+-----------------+
| PRIVACY              |            |                |                 |
| ACT/PAPERWORK        |            |                |                 |
| REDUCTION ACT        |            |                |                 |
| STATEMENT            |            |                |                 |
|                      |            |                |                 |
| The Office of        |            |                |                 |
| Surface Mining (OSM) |            |                |                 |
| is authorized to     |            |                |                 |
| ensure and certify   |            |                |                 |
| that all blasting    |            |                |                 |
| operations are       |            |                |                 |
| conducted by trained |            |                |                 |
| and competent        |            |                |                 |
| persons under        |            |                |                 |
| sections             |            |                |                 |
| 515(b)(15)(D) and    |            |                |                 |
| 719 of the Surface   |            |                |                 |
| Mining Control and   |            |                |                 |
| Reclamation Act of   |            |                |                 |
| 1977. The            |            |                |                 |
| information you put  |            |                |                 |
| on this form is      |            |                |                 |
| necessary to see how |            |                |                 |
| well your education  |            |                |                 |
| and work skills      |            |                |                 |
| quality you for the  |            |                |                 |
| position of          |            |                |                 |
| certified blaster.   |            |                |                 |
| You will not be      |            |                |                 |
| considered for       |            |                |                 |
| certification if you |            |                |                 |
| do not answer these  |            |                |                 |
| questions. Response  |            |                |                 |
| to this request is   |            |                |                 |
| required to obtain a |            |                |                 |
| benefit. You are not |            |                |                 |
| required to respond  |            |                |                 |
| to this collection   |            |                |                 |
| of information       |            |                |                 |
| unless it displays a |            |                |                 |
| currently valid OMB  |            |                |                 |
| control number.      |            |                |                 |
|                      |            |                |                 |
| We must have your    |            |                |                 |
| Social Security      |            |                |                 |
| Number (SSN) to keep |            |                |                 |
| your records         |            |                |                 |
| correct, since other |            |                |                 |
| people may have the  |            |                |                 |
| same birth date and  |            |                |                 |
| name. The SSN has    |            |                |                 |
| been used to keep    |            |                |                 |
| records since 1943   |            |                |                 |
| when Executive Order |            |                |                 |
| 9397 asked agencies  |            |                |                 |
| to do so. OSM may    |            |                |                 |
| also use your SSN to |            |                |                 |
| make requests about  |            |                |                 |
| you from employers,  |            |                |                 |
| schools, or from any |            |                |                 |
| other source you     |            |                |                 |
| provide on this      |            |                |                 |
| form, but only as    |            |                |                 |
| allowed by law. The  |            |                |                 |
| information          |            |                |                 |
| collected by using   |            |                |                 |
| your SSN will be     |            |                |                 |
| used only to check   |            |                |                 |
| the validity of the  |            |                |                 |
| answers on this      |            |                |                 |
| application and will |            |                |                 |
| not be used for any  |            |                |                 |
| studies or           |            |                |                 |
| statistical          |            |                |                 |
| purposes.            |            |                |                 |
|                      |            |                |                 |
| Information we have  |            |                |                 |
| about you may also   |            |                |                 |
| be given to Federal, |            |                |                 |
| State, and local     |            |                |                 |
| agencies for         |            |                |                 |
| checking on          |            |                |                 |
| violations or for    |            |                |                 |
| other lawful         |            |                |                 |
| purposes.            |            |                |                 |
|                      |            |                |                 |
| Public reporting     |            |                |                 |
| burden for this form |            |                |                 |
| is estimated to      |            |                |                 |
| average 2 hours per  |            |                |                 |
| response for         |            |                |                 |
| renewals/reciprocity |            |                |                 |
| and 4 hours for      |            |                |                 |
| issuances, including |            |                |                 |
| the time for         |            |                |                 |
| reviewing            |            |                |                 |
| instructions,        |            |                |                 |
| gathering and        |            |                |                 |
| maintaining data,    |            |                |                 |
| and completing and   |            |                |                 |
| reviewing the form.  |            |                |                 |
| Direct comments      |            |                |                 |
| regarding the burden |            |                |                 |
| estimate or any      |            |                |                 |
| other aspect of this |            |                |                 |
| form to the          |            |                |                 |
| Information          |            |                |                 |
| Collection Clearance |            |                |                 |
| Officer, OSM, Room   |            |                |                 |
| 202 SIB, 1951        |            |                |                 |
| Constitution Ave,    |            |                |                 |
| NW, Washington, DC   |            |                |                 |
| 20240.               |            |                |                 |
+----------------------+------------+----------------+-----------------+

OSM 74

+--------------------------------------------------+-------------------+
| 15\. EMPLOYMENT HISTORY AND BLASTING EXPERIENCE  |                   |
| (BEGIN WITH CURRENT OR MOST RECENT JOB)          |                   |
+--------------------------------------------------+-------------------+
| A. Company's Name and Address Dates Employed     |                   |
| (Mo. & Yr.)                                      |                   |
+--------------------------------------------------+-------------------+
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Blasting          |
|                                                  | Experience        |
|                                                  |                   |
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's Name |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's      |
|                                                  | Telephone Number  |
+--------------------------------------------------+-------------------+
|                                                  | Your Title        |
+--------------------------------------------------+-------------------+
| Description of Your Blasting Duties              |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
| B. Company's Name and Address Dates Employed     |                   |
| (Mo. & Yr.)                                      |                   |
+--------------------------------------------------+-------------------+
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Blasting          |
|                                                  | Experience        |
|                                                  |                   |
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's Name |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's      |
|                                                  | Telephone Number  |
+--------------------------------------------------+-------------------+
|                                                  | Your Title        |
+--------------------------------------------------+-------------------+
| Description of Your Blasting Duties              |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+

+--------------------------------------------------+-------------------+
| C. Company's Name and Address Dates Employed     |                   |
| (Mo. & Yr.)                                      |                   |
+--------------------------------------------------+-------------------+
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Blasting          |
|                                                  | Experience        |
|                                                  |                   |
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's Name |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's      |
|                                                  | Telephone Number  |
+--------------------------------------------------+-------------------+
|                                                  | Your Title        |
+--------------------------------------------------+-------------------+
| Description of Your Blasting Duties              |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
| D. Company's Name and Address Dates Employed     |                   |
| (Mo. & Yr.)                                      |                   |
+--------------------------------------------------+-------------------+
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Blasting          |
|                                                  | Experience        |
|                                                  |                   |
|                                                  | From: To:         |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's Name |
+--------------------------------------------------+-------------------+
|                                                  | Supervisor's      |
|                                                  | Telephone Number  |
+--------------------------------------------------+-------------------+
|                                                  | Your Title        |
+--------------------------------------------------+-------------------+
| Description of Your Blasting Duties              |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
|                                                  |                   |
+--------------------------------------------------+-------------------+
| (INCLUDE ADDITIONAL PAGES IF NEEDED)             |                   |
+--------------------------------------------------+-------------------+

+---------------+---------+-------------+-------------------+--------+
| 16\.          |         |             |                   |        |
| EDUCATION AND |         |             |                   |        |
| TRAINING      |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| A. Levels of  |         |             |                   |        |
| Education     |         |             |                   |        |
| Completed     |         |             |                   |        |
| (Circle       |         |             |                   |        |
| Highest Grade |         |             |                   |        |
| Completed in  |         |             |                   |        |
| Each School)  |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| 1\. Grade     | School  |             |                   |        |
| School 1 2 3  | Name    |             |                   |        |
| 4 5 6 7 8     | City    |             |                   |        |
|               | State   |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| 2\. High      | School  |             |                   |        |
| School 9 10   | Name    |             |                   |        |
| 11 12         | City    |             |                   |        |
|               | State   |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| 3\. College 1 | School  |             |                   |        |
| 2 3 4         | Name    |             |                   |        |
|               | City    |             |                   |        |
|               | State   |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| B. Blaster    |         |             |                   |        |
| Training in   |         |             |                   |        |
| the Storage,  |         |             |                   |        |
| T             |         |             |                   |        |
| ransportation |         |             |                   |        |
| and Use of    |         |             |                   |        |
| Explosives    |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| School Name & |         | Dates (Mo.  | Courses           | Total  |
| Location      |         | & Yr.)      |                   | Hours  |
|               |         |             |                   |        |
|               |         |             |                   | of     |
|               |         |             |                   | Tr     |
|               |         |             |                   | aining |
+---------------+---------+-------------+-------------------+--------+
|               |         | From        |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         | To          |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         | From        |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         | To          |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         | From        |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         | To          |                   |        |
+---------------+---------+-------------+-------------------+--------+
| C. Other      |         |             |                   |        |
| Related       |         |             |                   |        |
| Training      |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
|               |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| 17\. BLASTER  |         |             |                   |        |
| CERTIFICATION |         |             |                   |        |
| HISTORY       |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+
| A. Present    |         |             |                   |        |
| status (check |         |             |                   |        |
| appropriate   |         |             |                   |        |
| box or boxes) |         |             |                   |        |
|               |         |             |                   |        |
| ⁭I do not      |         |             |                   |        |
| presently     |         |             |                   |        |
| hold a        |         |             |                   |        |
| blaster       |         |             |                   |        |
| certificate   |         |             |                   |        |
| or license.   |         |             |                   |        |
|               |         |             |                   |        |
| ⁭I hold a ⁭     |         |             |                   |        |
| blaster       |         |             |                   |        |
| certificate   |         |             |                   |        |
| or ⁭ license   |         |             |                   |        |
| issued by ⁭    |         |             |                   |        |
| OSM or the ⁭   |         |             |                   |        |
| State of      |         |             |                   |        |
| \_\_\_\_\_\   |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
|               |         |             |                   |        |
| Date issued   |         |             |                   |        |
| \_\_\_\_\     |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_, |         |             |                   |        |
| Expiration    |         |             |                   |        |
| date          |         |             |                   |        |
| \_\_\_\       |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_, |         |             |                   |        |
| No.           |         |             |                   |        |
| \             |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
|               |         |             |                   |        |
| B. Have you   |         |             |                   |        |
| previously    |         |             |                   |        |
| held any      |         |             |                   |        |
| other blaster |         |             |                   |        |
| certificate   |         |             |                   |        |
| or license    |         |             |                   |        |
| that was not  |         |             |                   |        |
| revoked or    |         |             |                   |        |
| suspended? ⁭   |         |             |                   |        |
| No ⁭ Yes       |         |             |                   |        |
|               |         |             |                   |        |
| Issuer        |         |             |                   |        |
| \_\_\_\       |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| Date issued   |         |             |                   |        |
| \_\_\_\_\_\_  |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
|               |         |             |                   |        |
| Expiration    |         |             |                   |        |
| date          |         |             |                   |        |
| \_\_\_\_\_    |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_, |         |             |                   |        |
| No.           |         |             |                   |        |
| \_\_\_\_\_\_  |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
|               |         |             |                   |        |
| C. Has your   |         |             |                   |        |
| blaster       |         |             |                   |        |
| certificate   |         |             |                   |        |
| or license    |         |             |                   |        |
| ever been     |         |             |                   |        |
| revoked or    |         |             |                   |        |
| suspended, or |         |             |                   |        |
| has           |         |             |                   |        |
| disciplinary  |         |             |                   |        |
| action ever   |         |             |                   |        |
| been taken    |         |             |                   |        |
| against you   |         |             |                   |        |
| involving     |         |             |                   |        |
| your blaster  |         |             |                   |        |
| certificate   |         |             |                   |        |
| or license?   |         |             |                   |        |
|               |         |             |                   |        |
| ⁭No.           |         |             |                   |        |
|               |         |             |                   |        |
| ⁭Yes.          |         |             |                   |        |
| Describe:     |         |             |                   |        |
| \_\_          |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \             |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
| \_\_\_\_\_\_\ |         |             |                   |        |
| _\_\_\_\_\_\_ |         |             |                   |        |
+---------------+---------+-------------+-------------------+--------+

+-----------------------------------------------------------------------+
| 18\. LAW VIOLATION HISTORY                                            |
+-----------------------------------------------------------------------+
| When answering A or B below, you may omit (1) traffic offenses for    |
| which you paid a fine of \$50 or less; (2) any offense committed      |
| before your 18^th^ birthday which was satisfactorily addressed in a   |
| juvenile court or under a youth offender law; (3) any conviction the  |
| record of which has been deleted under Federal or State law; and (4)  |
| any conviction set aside under the Federal Youth Correction Act or    |
| similar authority.                                                    |
|                                                                       |
| A. Have you ever been convicted, forfeited collateral, or presently   |
| under charges for any felony or any firearms or explosives offense    |
| against the law?                                                      |
|                                                                       |
| > ⁭ No.                                                                |
|                                                                       |
| ⁭Yes. Describe:                                                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| B. During the past 6 years have you been convicted, imprisoned,       |
| placed on probation or parole or forfeited collateral, or are you now |
| under charges for any offense against the law not included in A       |
| above?                                                                |
|                                                                       |
| > ⁭ No.                                                                |
|                                                                       |
| ⁭Yes. Describe:                                                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| 19\. AFFIRMATION                                                      |
+-----------------------------------------------------------------------+
| I affirm that all the information provided by me in this application  |
| is true and correct to the best of my knowledge and belief and is     |
| provided in good faith. I authorize the Office of Surface Mining to   |
| check with the organizations and individuals I have identified in     |
| this application in order to verify the information I have provided.  |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Date Signature (Sign in ink)                                          |
|                                                                       |
| Mail completed application and fees to the address indicated below.   |
|                                                                       |
| +--------------------------------+--------------------------------+   |
| | If your address is EAST of the | If your address is WEST of the |   |
| | Mississippi River:             | Mississippi River:             |   |
| |                                |                                |   |
| | > Field Office Director        | > Field Office Director        |   |
| | >                              | >                              |   |
| | > Office of Surface Mining     | > Office of Surface Mining     |   |
| | >                              | >                              |   |
| | > Knoxville Field Office       | > Evergreen Plaza Building,    |   |
| | >                              | >                              |   |
| | > 530 Gay Street, Suite 500    | > Suite 703, 711 Capitol Way   |   |
| | >                              | >                              |   |
| | > Knoxville, Tennessee 37902   | > Olympia, Washington 98501    |   |
| |                                | >                              |   |
| |                                | > *Or*                         |   |
| |                                | >                              |   |
| |                                | > Field Office Director        |   |
| |                                | >                              |   |
| |                                | > Office of Surface Mining     |   |
| |                                | >                              |   |
| |                                | > Suite 1200,                  |   |
| |                                | >                              |   |
| |                                | > 505 Marquette Avenue, N.W.   |   |
| |                                | >                              |   |
| |                                | > Albuquerque, New Mexico      |   |
| |                                | > 87102                        |   |
| +--------------------------------+--------------------------------+   |
+-----------------------------------------------------------------------+