OSMRE-74 Expires: 4/30/2024

U.S. DEPARTMENT OF THE INTERIOR 

OFFICE OF SURFACE MINING 

RECLAMATION AND ENFORCEMENT 

(OSMRE)

APPLICATION FOR AN OSM BLASTER CERTIFICATE

OSMRE Form 74

GENERAL INSTRUCTIONS

1. Furnish all requested information. Information provided on this

application will strongly influence OSMRE’s decision to grant

an OSMRE blaster certificate.

2. Use additional sheets if more space is needed to complete any

of the items. Indicate at the top of each additional sheet your

full name, social security number, and item number. Insert the

sheet between the pages of this application.

3. Be sure to include with your application all other forms

required (for example, see the statement required under Item 16

of “” Education and Training”).

4. Any experience which you want counted as on-the-job training

must be accompanied by a statement describing the training and

signed by the supervisor.

INSTRUCTIONS TO SPECIFIC ITEMS

ITEMS 1 THRU 12. Self-Explanatory.

ITEM 13. Type of Certificate You Are Applying For.

 Check “Issue” if this is an application for 

your first certificate.

 Check “Renewal” if this application is for a 

certification that is being renewed; one that was issued 

approximately three years ago.

 Check “Reissue” if this application is for a 

certification that follows a prior certification (Not a 

renewal) that was issued six years ago.

 Check “Replacement” if your original 

certificate has been lost and you are applying for a 

replacement.

 Check “Reciprocity” if you are a certified 

blaster holding a current blaster certificate under an OSM 

approved State program.

ITEM 14. Examination Date.

Contact the nearest OSMRE Field Office for dates.

ITEM 15. Employment History and Blasting Experience.

List the last six years of work experience, starting with your most recent 

job in blasting and work back in time (month and year). Include 

additional pages, if needed. If there was a break in employment with 

one company, treat each period of employment as a separate job. 

Include the company name and address. List your immediate supervisor 

and his/her work telephone number, if known. If you do not know 

his/her work number, give the phone number of the company where 

your supervisor may be located. Show your full title and provide a full 

description of your work.

ITEM 16. Education and Training.

Section A - Complete the educational background information.

Section B - List the type of formal classroom and on-the-job blasting 

related training you have received.

Section C - Describe any other training that you have had, such as, 

training in mining equipment operations, mining methods, 

other related equipment operations, etc.

Include training vouchers, certificates, or other proof of satisfactory 

completion of training courses and seminars listed in Items 16B and 

16C.

ITEM 17. Blaster Certification History.

Section A - List any blaster licenses/certifications that you currently 

possess along with the number and status .

Section B - Describe any instance where disciplinary action has been 

taken against your license or certification. This includes but

is not limited to letters, suspensions, revocations, etc. . . 

Describe the circumstances and the outcome of each case. 

Include any civil or criminal charges that may have arisen 

out of these actions and the resolution to those charges.

Section C. – Provide your most recent valid Letter of Clearance from the 

Bureau of Alcohol, Tobacco Firearms and Explosives 

(ATF)

ITEM 18. Affirmation.

Date and sign in ink.

INCLUDE CHECK OR MONEY ORDER MADE PAYABLE 

TO: OFFICE OF SURFACE MINING RECLAMATION 

AND ENFORCEMENT (OSMRE)

TYPE OR PRINT ALL INFORMATION IN INK.
OSMRE-74 Expires: 4/30/2024

U.S. DEPARTMENT OF THE INTERIOR

OFFICE OF SURFACE MINING

APPLICATION FOR AN OSMRE BLASTER CERTIFICATE

OMB No. 1029-0083 

Expires: 4/30/2024

Please Read Instructions Before Completing

1. Name (last, first, middle initial) DO NOT WRITE IN THIS 

BLOCK (for OSMRE use only) 

2. Mailing Address (Street, Route, P.O. Box) Date Application Received

3. City State Zip Application Complete

⁭ Yes ⁭ No

4. Home Telephone Number (include area code) 5. Office Telephone Number (include area code) Amount Fee Received

$

6. Date of Birth (month, day, year) 7. Social Security Number (Voluntary, will help prevent 

misidentification)

Examination Date

8. Sex

⁭ Male ⁭ Female

9. Color of Hair Examination Rating

10. Height

feet inches

11. Weight

pounds

12. Color of Eyes Certificate Number and Date Issued

13. TYPE OF CERTIFICATE (FEE IS SHOWN IN PARENTHESES)

Check 

Box

Certification Type Complete Sections Cost

Issue All $122.00

Re-issue All $122.00

Renewal 1-13, 15, 17, 18 $61.00

Reciprocity All $61.00

Replacement 1-13, 18 $28.00

Re-Examination 1-13, 18 $61.00

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: .

PRIVACY ACT/PAPERWORK REDUCTION ACT STATEMENT 

The Office of Surface Mining Reclamation and Enforcement (OSMRE) 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 qualify 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. OSMRE 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 1 hour per response, 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, OSMRE, 1849 C. Street, NW, Room 4556 MIB, Washington, DC 20240. 
OSMRE-74 Expires: 4/30/2024

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
OSMRE-74 Expires: 4/30/2024

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)
OSMRE-74 Expires: 4/30/2024

16. EDUCATION AND TRAINING

A. Level of Education Completed: 

Enter the highest level of education completed ___________________________________________ (for example: 5th, 8th, 12th, GED, Bachelors Degree, etc.)

Enter the school information where the highest level of education or equivalent was obtained:

School Name City State

___________________________________________________________ ____________________________________________ ________

B. Blaster training in the storage, transportation and use of explosives (attach proof of completion). Note: If you are applying for reissuance, list the 24 hours of 

continuing education received during the last 6 years and attach proof of completion.

School Name & Location Dates (Mo. & Yr.) Courses Total Hours 

of Training

From

To

From

To

From

To

C. Other Related Training (attach proof of completion)

17. BLASTER CERTIFICATION HISTORY

Current Licenses or Certificates

A. List all Licenses and Certificates that you currently possess and provide a copy of each.

Certificate/ License Name State Number Issue Date Expiration Date Status

B. 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: _____________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

C. Provide a copy of your most recent valid ATF Letter of Clearance.
OSMRE-74 Expires: 4/30/2024

18. 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 Reclamation and Enforcement 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 closest address indicated below.

Office of Surface Mining Reclamation and Enforcement

710 Locust St. 2nd Floor

Knoxville, Tennessee 37902

Office of Surface Mining Reclamation and Enforcement

501 Belle Street, Suite 216

Alton, Illinois 62002 

Office of Surface Mining Reclamation and Enforcement

Dick Cheney Federal Building

POB 11018, 150 East “B” Street

Casper, WY 82601-7032

Office of Surface Mining Reclamation and Enforcement 

Evergreen Plaza Building, Suite 703

711 Capitol Way 

Olympia, Washington 98501 

Office of Surface Mining Reclamation and Enforcement 

Albuquerque Area Office

100 Sun Avenue, NE Suite 330

Albuquerque, NM 87109