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Representative of Miners Designation Form

Form ID

This voluntary form is a written declaration of any person or organization which represents two or more miners at a coal or other mine for the purposes of the Mine Act.

Control ID
Expiration Date
Thu, 12/31/2026 - 13:00
Filing Options

Fill in, print and mail or fax
File online
Change online filing registration information

This notification may also be filed by submitting a printed letter to your local MSHA District Office .

Contact Information

Questions regarding this form should be directed to MSHA at (877) 778-6055 or

Privacy Notice
Burden Statement

Public reporting burden for this collection of information estimated to average 10 minutes per response; including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date need, and completing and reviewing the collection of information. Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety & Health Administration, U.S. Department of Labor, Office of Standards, Regulations and Variances, 201 12th Street South, Suite 401 Arlington, VA 22202-5450. Persons are not required to respond to this collection of information unless it displays a currently OMB Control Number.