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.
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 .
Questions regarding this form should be directed to MSHA at (877) 778-6055 or desk.help@dol.gov
Send comments regarding the collection of information, including suggestions for reducing this burden, to the Mine Safety and Health Administration, U.S. Department of Labor, Office of Standards, Regulations and Variances, 200 Constitution Avenue, NW, Room C3522, Washington, DC 20210. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. NOTE: Do not send your completed form to this address.