Form OSMRE Form 74 OSMRE Form 74 APPLICATION FOR AN OSM BLASTER CERTIFICATE

U.S. DEPARTMENT OF THE INTERIOR
OFFICE OF SURFACE MINING
RECLAMATION AND ENFORCEMENT
(OSMRE)
APPLICATION FOR AN OSM BLASTER CERTIFICATE
OSMRE Form 74
GENERAL INSTRUCTIONS

ITEM 15. Employment History and Blasting Experience.

1.

Furnish all requested information. Information provided on this
application will strongly influence OSMRE’s decision to grant
an OSMRE blaster certificate.

2.

Use additional sheets if more space is needed to complete any
of the items. Indicate at the top of each additional sheet your
full name, social security number, and item number. Insert the
sheet between the pages of this application.

3.

Be sure to include with your application all other forms
required (for example, see the statement required under Item 16
of “” Education and Training”).

4.

Any experience which you want counted as on-the-job training
must be accompanied by a statement describing the training and
signed by the supervisor.

INSTRUCTIONS TO SPECIFIC ITEMS
ITEMS 1 THRU 12. Self-Explanatory.
ITEM 13. Type of Certificate You Are Applying For.






Check “Issue” if this is an application for
your first certificate.
Check “Renewal” if this application is for a
certification that is being renewed; one that was issued
approximately three years ago.
Check “Reissue” if this application is for a
certification that follows a prior certification (Not a
renewal) that was issued six years ago.
Check “Replacement” if your original
certificate has been lost and you are applying for a
replacement.
Check “Reciprocity” if you are a certified
blaster holding a current blaster certificate under an OSM
approved State program.

List the last six years of work experience, starting with your most recent
job in blasting and work back in time (month and year). Include
additional pages, if needed. If there was a break in employment with
one company, treat each period of employment as a separate job.
Include the company name and address. List your immediate supervisor
and his/her work telephone number, if known. If you do not know
his/her work number, give the phone number of the company where
your supervisor may be located. Show your full title and provide a full
description of your work.

ITEM 16. Education and Training.
Section A - Complete the educational background information.
Section B - List the type of formal classroom and on-the-job blasting
related training you have received.
Section C - Describe any other training that you have had, such as,
training in mining equipment operations, mining methods,
other related equipment operations, etc.
Include training vouchers, certificates, or other proof of satisfactory
completion of training courses and seminars listed in Items 16B and
16C.

ITEM 17. Blaster Certification History.
Section A - List any blaster licenses/certifications that you currently
possess along with the number and status .
Section B - Describe any instance where disciplinary action has been
taken against your license or certification. This includes but
is not limited to letters, suspensions, revocations, etc. . .
Describe the circumstances and the outcome of each case.
Include any civil or criminal charges that may have arisen
out of these actions and the resolution to those charges.
Section C. – Provide your most recent valid Letter of Clearance from the
Bureau of Alcohol, Tobacco Firearms and Explosives
(ATF)

ITEM 18. Affirmation.
Date and sign in ink.

ITEM 14. Examination Date.
Contact the nearest OSMRE Field Office for dates.

INCLUDE CHECK OR MONEY ORDER MADE PAYABLE
TO: OFFICE OF SURFACE MINING RECLAMATION
AND ENFORCEMENT (OSMRE)

TYPE OR PRINT ALL INFORMATION IN INK.

OSMRE-74 Expires: 4/30/2021

U.S. DEPARTMENT OF THE INTERIOR
OFFICE OF SURFACE MINING
APPLICATION FOR AN OSMRE BLASTER CERTIFICATE
OMB No. 1029-0083
Expires: 4/30/2021

Please Read Instructions Before Completing
1. Name (last, first, middle initial)

DO NOT WRITE IN THIS
BLOCK (for OSMRE use only)

2. Mailing Address (Street, Route, P.O. Box)

Date Application Received

3. City

State

Zip

Application Complete


4. Home Telephone Number (include area code)

5. Office Telephone Number (include area code)

Yes

 No

Amount Fee Received
$

6. Date of Birth (month, day, year)

7. Social Security Number (Voluntary, will help prevent
misidentification)

Examination Date

8. Sex

9. Color of Hair

Examination Rating



Male



Female

10. Height

11. Weight
feet

12. Color of Eyes

inches

Certificate Number and Date Issued

pounds

13. TYPE OF CERTIFICATE (FEE IS SHOWN IN PARENTHESES)
Check
Box

Certification Type

Complete Sections

Cost

Issue

All

$122.00

Re-issue

All

$122.00

Renewal

1-13, 15, 17, 18

$61.00

Reciprocity

All

$61.00

Replacement

1-13, 18

$28.00

Re-Examination

1-13, 18

$61.00

14. If this application is for an ISSUE or REISSUE certification, indicate date and location, if known, of examination you wish to take.
Date:

Location:

.

PRIVACY ACT/PAPERWORK REDUCTION ACT STATEMENT
The Office of Surface Mining Reclamation and Enforcement (OSMRE) is authorized to ensure and certify that all blasting operations are conducted by trained
and competent persons under sections 515(b)(15)(D) and 719 of the Surface Mining Control and Reclamation Act of 1977. The information you put on this
form is necessary to see how well your education and work skills qualify you for the position of certified blaster. You will not be considered for certification
if you do not answer these questions. Response to this request is required to obtain a benefit. You are not required to respond to this collection of information
unless it displays a currently valid OMB control number.
We must have your Social Security Number (SSN) to keep your records correct, since other people may have the same birth date and name. The SSN has
been used to keep records since 1943 when Executive Order 9397 asked agencies to do so. OSMRE may also use your SSN to make requests about you from
employers, schools, or from any other source you provide on this form, but only as allowed by law. The information collected by using your SSN will be used
only to check the validity of the answers on this application and will not be used for any studies or statistical purposes.
Information we have about you may also be given to Federal, State, and local agencies for checking on violations or for other lawful purposes.
Public reporting burden for this form is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining
data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection
Clearance Officer, OSMRE, 1849 C. Street, NW, Room 4559 MIB, Washington, DC 20240.

OSMRE-74 Expires: 4/30/2021

15. EMPLOYMENT HISTORY AND BLASTING EXPERIENCE (BEGIN WITH CURRENT OR MOST RECENT JOB)
A. Company’s Name and Address

Dates Employed (Mo. & Yr.)
From:

To:

Blasting Experience
From:

To:

Supervisor’s Name

Supervisor’s Telephone Number

Your Title

Description of Your Blasting Duties

B. Company’s Name and Address

Dates Employed (Mo. & Yr.)
From:

To:

Blasting Experience
From:

To:

Supervisor’s Name

Supervisor’s Telephone Number

Your Title

Description of Your Blasting Duties

OSMRE-74

Expires: 4/30/2021

C. Company’s Name and Address

Dates Employed (Mo. & Yr.)
From:

To:

Blasting Experience
From:

To:

Supervisor’s Name

Supervisor’s Telephone Number

Your Title

Description of Your Blasting Duties

D. Company’s Name and Address

Dates Employed (Mo. & Yr.)
From:

To:

Blasting Experience
From:

To:

Supervisor’s Name

Supervisor’s Telephone Number

Your Title

Description of Your Blasting Duties

(INCLUDE ADDITIONAL PAGES IF NEEDED)
OSMRE-74

Expires: 4/30/2021

16. EDUCATION AND TRAINING
A. Level of Education Completed:
Enter the highest level of education completed ___________________________________________ (for example: 5th, 8th, 12th, GED, Bachelors Degree, etc.)
Enter the school information where the highest level of education or equivalent was obtained:
School Name

City

State

___________________________________________________________

____________________________________________

________

B. Blaster training in the storage, transportation and use of explosives (attach proof of completion). Note: If you are applying for reissuance, list the 24 hours of
continuing education received during the last 6 years and attach proof of completion.
School Name & Location

Dates (Mo. & Yr.)

Courses

Total Hours
of Training

From
To
From
To
From
To
C. Other Related Training (attach proof of completion)

17. BLASTER CERTIFICATION HISTORY
Current Licenses or Certificates
A. List all Licenses and Certificates that you currently possess and provide a copy of each.
Certificate/ License Name

State

Number

Issue Date

Expiration Date

Status

B. Has your blaster certificate or license ever been revoked or suspended, or has disciplinary action ever been taken against you involving
your blaster certificate or license?




No.

Yes. Describe: _____________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
C. Provide a copy of your most recent valid ATF Letter of Clearance.
OSMRE-74

Expires: 4/30/2021

18. AFFIRMATION
I affirm that all the information provided by me in this application is true and correct to the best of my knowledge and belief and is provided in
good faith. I authorize the Office of Surface Mining Reclamation and Enforcement to check with the organizations and individuals I have
identified in this application in order to verify the information I have provided.

_______________________
Date

________________________________________________________
Signature (Sign in ink)

Mail completed application and fees to the closest address indicated below.
Office of Surface Mining Reclamation and Enforcement
710 Locust St. 2nd Floor
Knoxville, Tennessee 37902
Office of Surface Mining Reclamation and Enforcement
501 Belle Street, Suite 216
Alton, Illinois 62002
Office of Surface Mining Reclamation and Enforcement
Dick Cheney Federal Building
POB 11018, 150 East “B” Street
Casper, WY 82601-7032

OSMRE-74

Expires: 4/30/2021

Office of Surface Mining Reclamation and Enforcement
Evergreen Plaza Building, Suite 703
711 Capitol Way
Olympia, Washington 98501
Office of Surface Mining Reclamation and Enforcement
Albuquerque Area Office
100 Sun Avenue, NE Suite 330
Albuquerque, NM 87109