Official Federal Forms > US Dept Of Labor
Certificate Of Electrical Training MSHA 5000-1 - Official Federal Forms
| Certificate Of Electrical Training Form. This is a national form and can be used in US Dept Of Labor . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Certificate of Electrical Training 7KLV IRUP LV DIIHFWHG E\ WKH 3ULYDF\ $FW RI U.S. Department of Labor Mine Safety and Health Administration )RUP $SSURYHG 20% 1XPEHU $SSURYDO ([SLUHV 2FWREHU Item 1. &RPSDQ\ 1DPH DQG $GGUHVV LI WKH DGGUHVV EHORZ LV EODQN LQIRUPDWLRQ ZLOO EH VHQW WR DGGUHVV VHOHFWHG LQ ,WHP &RPSDQ\ 1DPH $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS Item 2. 0LQH ,' RU &RQWUDFWRU ,' Item 3. ,QVWUXFWRU 1DPH Item 7. 'DWH &RPSOHWHG 00''<<<< Item 4. ,QVWUXFWRU¶V 06+$ ,QGLYLGXDO ,GHQWLILFDWLRQ 1XPEHU 0,,1 Item 5. &RXQW\ DQG 6WDWH :KHUH 7UDLQLQJ 7RRN 3ODFH 6WDWH /HWWHU $OSKD Item 6. $552( 1R MSHA only) Item 11. (OHFWULFDO &RGHV Underground Retraining (EC) Item 12. 06+$ 8VH 2QO\ Underground Reinstatement (RU) RU RU RU Surface Reinstatement (RS) RS RS RS Underground Initial (EB) Item 8. 06+$ ,QGLYLGXDO ,GHQWLILFDWLRQ 1XPEHU 0,,1 DQG DGGUHVV VHOHFWRU MIIN Item 9. 1DPH /DVW )LUVW 0 /DVW 1DPH Item 10. 0LQHU 5HTXHVWHG 6HQG 7R $GGUHVV $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS 1 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH EB ED EC EE MIIN /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS EB ED EC EE 2 MIIN /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS EB ED EC EE 3 06+$ )RUP )HE 5HYLVHG 3UHYLRXV (GLWLRQV DUH 2EVROHWH 3DJH RI American LegalNet, Inc. www.FormsWorkFlow.com Surface Retraining (EE) Surface Initial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omputer Security Guidelines for Implementing the Privacy Act of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nderground Retraining (EC) Underground Reinstatement (RU) RU RU RU RU RU Certificate of Electrical Training 06+$ 4XDOLILFDWLRQ &HUWLILFDWLRQ 8QLW 32 %R[ ')& 'HQYHU &2 3KRQH )D[ $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS MIIN /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH 4 EB ED Surface Initial (ED) Return to: EC EE RS MIIN /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS EB ED EC EE RS 5 MIIN /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS EB ED EC EE RS 6 MIIN $WWQ /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, $WWQ 6WUHHW 6WUHHW &LW\ 6WDWH =LS EB ED EC EE RS 7 6WUHHW 6WUHHW &LW\ 6WDWH =LS EB ED EC EE RS )LUVW 1DPH MIIN /DVW 1DPH 0LQH $GGUHVV 06+$ )LOH &RQWUDFWRU $GGUHVV 06+$ )LOH &RPSDQ\ $GGUHVV ,WHP 0LQHU 5HTXHVWHG 6HQG WR $GGUHVV ,WHP 0, )LUVW 1DPH 8 )DOVH FHUWLILFDWLRQ LV SXQLVKDEOH XQGHU VHFWLRQ D DQG I RI WKH )HGHUDO 0LQH 6DIHW\ DQG +HDOWK $FW 3/ DV DPHQGHG E\ 3/ Item 13. 6LJQDWXUH IRU ,QVWUXFWRU , FHUWLI\ WKDW WKH DERYH LQGLYLGXDOV KDYH FRPSOHWHG WKH FRXUVHV LQGLFDWHG 06+$ )RUP )HE 5HYLVHG 3UHYLRXV (GLWLRQV DUH 2EVROHWH 3DJH RI American LegalNet, Inc. www.FormsWorkFlow.com Surface Reinstatement (RS) Underground Initial (EB) U.S. Department of Labor Mine Safety and Health Administration Surface Retraining (EE) Instructions for Completing MSHA Form 5000-1 Item 1. Company Name and Address ,I LQ ,WHP RQ WKH IRUP Company Address LV VHOHFWHG WKH IXOO QDPH DQG DGGUHVV RI WKH FRPSDQ\ LV UHTXLUHG 7KLV ZLOO EH WKH DGGUHVV XVHG WR PDLO WKH (OHFWULFDO 4XDOLILFDWLRQ FDUGV Item 2. Mine ID or Contractor ID 7KH 06+$ DVVLJQHG 0,' RU &,' QXPEHU PD\ EH ILOOHG LQ 7KLV QXPEHU ZDV DVVLJQHG E\ 06+$ ,I LQ ,WHP Mine Address RU Contractor Address LV VHOHFWHG WKHQ WKLV EHFRPHV D UHTXLUHG ILHOG 06+$ LV QR ORQJHU XVLQJ PLVFHOODQHRXV 0LQH ,G¶V RU &RQWUDFWRU ,'¶V H[DPSOH ;; DQG ;; Item 3. Instructor's Name (REQUIRED) 3URYLGH WKH /DVW 1DPH )LUVW 1DPH RI WKH LQVWUXFWRU ZKR JDYH WKH HOHFWULFDO WUDLQLQJ Item 4. Instructor's MSHA Individual Identification Number (MIIIN) (REQUIRED) 7KH 0,,1 QXPEHU LV DQ 06+$ DVVLJQHG QXPEHU WKDW DOO LQGLYLGXDOV PXVW REWDLQ WR EH XVHG IRU WUDLQLQJ VXEPLVVLRQV WR 06+$ DQG DOVR ZKHQ FRQWDFWLQJ 06+$ WR YHULI\ UHFRUGV ,I \RX QHHG WR REWDLQ D 0,,1 SOHDVH FRQWDFW WKH 4XDOLILFDWLRQ DQG &HUWLILFDWLRQ 8QLW DW RU Item 5. Name of the County and State Where Training Took Place (REQUIRED) &RXQW\ DQG 6WDWH LV UHTXLUHG WR SURYLGH LQIRUPDWLRQ WR WKH DSSURSULDWH GLVWULFW LI WKH 0,' RU &,' LV QRW XVHG Item 6. AR/ROE No. (Required if training provided by MSHA or MSHA is reinstating the qualification) 7KLV ILHOG LV 06+$ XVH RQO\ Item 7. Date Training Completed (REQUIRED) 7KH GDWH WKH WUDLQLQJ ZDV FRPSOHWHG Item 8. Individual Receiving Training MSHA Individual Identification Number (MIIN) 7KH 0,,1 QXPEHU LV DQ 06+$ DVVLJQHG QXPEHU WKDW DOO LQGLYLGXDOV PXVW REWDLQ WR EH XVHG IRU WUDLQLQJ VXEPLVVLRQV WR 06+$ DQG DOVR ZKHQ FRQWDFWLQJ 06+$ WR YHULI\ UHFRUGV ,I \RX QHHG WR REWDLQ D 0,,1 SOHDVH FRQWDFW
|
|||||||
