MR2-Application For Renewal of Blaster's Certification
Commonwealth of Kentucky
Environmental and Public Protection Cabinet
Department of Natural Resources
Division of Mine Reclamation & Enforcement
300 Sower Blvd., 2nd Floor
Frankfort, Kentucky 40601
APPLICATION FOR RENEWAL OF BLASTER’S CERTIFICATION
Name _____________________________ Social Security No. _ _ _- _ _ - _ _ _ _
Address ___________________________ Driver’s License No. ______________________
City _______________________________ Date of Birth _____________________________
State _________Zip Code ___________ Home Phone ( ___ )_____________________
Place of Employment ______________ Work Phone ( ___ )_____________________
___________________________________ Cell Phone (_______)______________________
Work Address ______________________ E-mail ___________________________________
City ___________________________________ Kentucky Blaster’s License No. ____________
State _________Zip Code ______________ Expiration Date ___________________________
Certification No. _________________________
IN ORDER TO RENEW YOU MUST (CHECK ONE)
______ PROVIDE A NOTARIZED REFERENCE LETTER(S) SHOWING YOU HAVE WORKED
AT LEAST 18 MONTHS (within the last 3 years) AS A BLASTER WITH A COAL MINING OPERATION OR
______ PROVIDE A NOTARIZED REFERENCE LETTER SHOWING YOU HAVE WORKED 18 MONTHS
(within the last 3 years) AS A BLASTER WITH A CONSTRUCTION OR NON-COAL OPERATION AND HAVE SUCCESSFULLY RETAKEN AND PASSED THE CABINET’S BLASTER EXAMINATION OR
______ RETAKEN AND SUCCESSFULLY PASSED THE CABINET’S AND THE OFFICE OF MINE SAFETY AND
LICENSING BLASTER EXAMINATIONS.
Mail application and all attachments including a $10.00 renewal fee made payable to the Kentucky State Treasurer to:
Department for Natural Resources
Division of Mine Reclamation & Enforcement
Blaster Certification
300 Sower Blvd., 2nd Floor
Frankfort, Kentucky 40601
I CERTIFY, UNDER PENALTY OF LAW, THAT THE INFORMATION GIVEN IN THIS APPLICATION IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DATE _____________________________ APPLICANT SIGNATURE __________________________________________
Form MR2 Revised 1/19
-----------------------
FOR DEPARTMENTAL USE ONLY
Renewal Date _____________________
Issuance Date ____________________ Expiration Date ___________________
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