Form OSM 105 OSM 105 Nominations for Non-Federal Personnel to Participate in

UNITED STATES DEPARTMENT OF THE INTERIOR

Office of Surface Mining Reclamation and Enforcement

NOMINATIONS FOR NON-FEDERAL PERSONNEL

TO PARTICIPATE IN OSM TECHNICAL TRAINING COURSES

OMB 1029-0120

Expiration Date: January 31, 2007

PART I: NOMINATION INFORMATION

1. Course Title:

2. Dates: 3. Location:

4. Nominee’s Name: (Last, First, MI) 5. Social Security No.: (Only If Requesting Payment For Travel)

6. Nominee’s Title: 7. Program: [ ] Title IV—AML

[ ] Title V—Regulatory

8. Nominee’s Work Phone No.: 9. Nominee’s E-mail Address:

10. Name of Agency:

11. Official Duty Station: (Complete Overnight Mailing Address) 12. Residence (City and State)

*Miles to training site: _________________________ *Miles to training site: _________________________

13. Supervisor’s Name and Address: 14. Supervisor’s E-Mail:

15. PLEASE CHECK APPLICABLE PRIORITY:

________a) Individuals whose functions relate directly to the course subject matter.

________b) Supervisors or support staff such as attorneys and managers whose functions relate directly to

the course matter.

________c) Individuals in established positions that relate indirectly to the course subject matter.

________d) State/Tribal members with planning, budgeting or other support or management responsibilities

to the course subject matter.

________e) Individuals from State or Tribal offices who provide indirect support to the regulatory authority,

State environmental protection staff and administrative staff.

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TURN TO PAGE 2—SIGNATURE REQUIRED

PART II: REQUEST FOR PAYMENT OF TRAVEL AND PER DIEM EXPENSES

9. 16. REQUESTED MODE OF TRAVEL:

[ ] Government-owned vehicle [ ] Common carrier (air)

[ ] Privately owned vehicle [ ] Other (specify)

[ ] Name of closest airport and number of miles to: ________________________________________________

[ ] Name of 2^nd closest airport and number of miles to: ______________________________________________

17. PER DIEM REQUESTED FOR:

[ ] Lodging Beginning Date: ___________________ Ending Date: _____________________

[ ] Meals and incidental expenses

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18. FUND REQUEST:

*We do not have funds available to pay travel and per diem expenses for the above nominees because:

[ ] Sufficient funds were not made available through legislature’s appropriation process.

[ ] As a practice, the State does not provide out-of-State travel authority for the purpose identified above.

[ ] Letter attached.

[ ] Other (Please explain briefly):

_____________________________________________________________

Authorized Signature

OSM 105 (rev.08/00)

PAPERWORK REDUCTION ACT STATEMENT

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. This information is being collected to calculate the type and number of classes and instructors needed to complete OSM’s technical training mission, and to estimate costs for our annual budget. The Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)(1)) permits a Federal agency to require each person doing business with that agency to furnish to that agency that person's taxpayer identification number. We collect personal data to reimburse participants in our training program. We do not use the information for any other internal secondary purpose. We may disclose information you give us if required by Federal law, such as the Privacy Act.

Public reporting burden for this form is estimated to average 5 minutes per response, including the time for reviewing the instructions, gathering and maintaining data, and completing and reviewing the form. Response is required to obtain a benefit. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, OSM, Room 202 SIB, 1951 Constitution Ave, NW, Washington, DC 20240.