2011 Foreman Application Form Revised

PLEASE TYPE OR PRINT CLEARLYDATE: _______________THE STATEOF WYOMINGWYOMING STATE MINE INSPECTORTERRY W. ADCOCKP. O. Box 1094Rock Springs, WY 82902TELEPHONE: 307-362-5222 FAX: 307-362-52332011MINE EXAMINER & FOREMAN CERTIFICATION APPLICATIONAPPLICANT’S NAME: ___________________________________________________________________HOME MAILING ADDRESS: ______________________________________________________________City: _______________________ST:____ Zip: ________APPLICANT’S PHONE #: ___________________DATE OF BIRTH: ________________LAST 4 DIGITS OF SOCIAL SECURITY NUMBER: ____________EMPLOYER'S NAME: _____________________________ MINE NAME: ___________________________Type of Exam applying for:UNDERGROUND Coal ______ Yrs. Experience EXAMINER Trona _____ Yrs. Experience FOREMAN Metal/Non-Metal _____Yrs. ExperienceSURFACE Coal _____Yrs. Experience EXAMINER or FOREMAN Metal/Non-Metal ____Yrs. ExperienceAPPLICANT’S CERTIFICATION:I hereby certify that I meet the qualifications for certification in the type of mining listed above as stated in W.S. § 30-2-309Mines and Minerals Statutes of the State of Wyoming.This form must be signed in the presence of a Notary._______________________________(Applicant’s Signature)The fee of $ 100.00 (check or money order – NO CASH) for each examination must accompany this application. MakeChecks/Money Order payable to State Mine Inspector. No Applications Will Be Accepted After March 31, 2011.Application Fee WILL NOT be refunded after acceptance by the Mining Council.ACKNOWLEDGEMENTState of ______________________County of ________________________The foregoing instrument was acknowledged before me by________________________________________________________,this ___________ day of _____________________, 20_____.Witness my hand and official seal._____________________________________________________Notary Public My Commission Expires: (Seal)2011 Foreman Application Form Revised.doc

AS PER WYOMING STATUTE W.S. § 30-2-309. MUST BE AT LEAST TWENTY-THREE (23) YEARS OF AGE. YOUMUST SHOW THREE (3) YEARS “HANDS ON” EXPERIENCE AT OR NEAR THE POINT OF EXTRACTION IN THETYPE OF MINERAL FOR WHICH YOU WISH TO BE CERTIFIED AS A FOREMAN, AND TWO (2) YEARS “HANDSON EXPERIENCE AT OR NEAR THE POINT OF EXTRACTION IN THE TYPE OF MINERAL FOR WHICH YOU WISHTO BE CERTIFIED AS AN EXAMINER.ARE YOU APPLYING FOR CREDIT FOR YOUR DEGREE? YES NOTo receive one (1) years’ credit for a degree listed in W.S. § 30-2-309(c), you must have the institution from which yougraduated send your transcript or proof of degree to the Mining Council at the address listed on this form. The Council willreview the applications on a case by case basis.ARE YOU APPLYING FOR EXPERIENCE CREDIT IN A DIFFERENT MINERAL? YES NOThe Council will consider experience in other minerals and types of mines, if they meet the criteria listed inW.S§ 30-2-309(a). The Council will review the applications on a case by case basis.WORK HISTORY: Start with Present Employer…..BE VERY SPECIFIC (Resumes may NOT be substituted for this section)COMPANY______________________________________________________________________________________ADDRESS_______________________________________________________________________________________TYPE OF MINE- SURFACE UNDERGROUND MINERAL MINED: __________________________________CURRENT COMPANY CONTACT: Name: ______________________________Phone:__________________________YEARS WORKED FROM: __________Month ________Year TO: __________ Month ___________YearBE VERY SPECIFIC (LIST TYPES OF WORK PERFORMED):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Previous EmployerCOMPANY_______________________________________________________________________________________ADDRESS_______________________________________________________________________________________TYPE OF MINE- SURFACE UNDERGROUND MINERAL MINED __________________________________CURRENT COMPANY CONTACT: Name: ______________________________Phone:__________________________YEARS WORKED FROM: __________Month ________Year TO: __________ Month ___________YearBE VERY SPECIFIC (LIST TYPES OF WORK PERFORMED):________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________For additional work history, attach a separate sheet2011 Foreman Application Form Revised.doc