DEQ COAL SECTION • PO BOX 200901 • HELENA MT 59620-0901 • PHONE: 406-444-4970 • FAX: 406-444-4988 • EMAIL: DEQCoal@mt.
gov
BLASTER CERTIFICATION PROGRAM
Application & Renewal Form
For Departmental Use Only
Please Type or Print Legibly
DO NOT Write in the Spaces Below
TYPE OF APPLICATION:
Certification Number
Certification Date NEW RENEWAL
Expiration Date
NAME OF APPLICANT: HEIGHT: WEIGHT:
MAILING ADDRESS: EYE COLOR: HAIR COLOR:
CITY: STATE: ZIP: BIRTH DATE: DRIVERS LICENSE NO:
ARE YOU CURRENTLY CERTIFIED UNDER ANOTHER STATE OR FEDERAL HAS YOUR BLASTER CERTIFICATION EVER BEEN
PROGAM? REVOKED?
YES NO YES NO
LIST PROGRAM AND CERTIFICATION NUMBERS IF YES, WHY?
1.) ATF -
2.)
APPLICANT’S EXPERIENCE RECORD* (List Most Recent Experience First.) *NOTE: Attach additional pages as necessary
FROM TO COMPANY FOREMAN TYPE OF BLASTING EXPERIENCE
MO/YR MO/YR (City, State)
TRAINING COURSES COMPLETED WITHIN THE LAST THREE YEARS (Attach Verification)
LENGTH OF NAME OF COURSE DATE COURSE COURSE DESCRIPTION
COURSE (HRS) COMPLETED
PRESENT EMPLOYER OR NAME OF BUSINESS: HOME PHONE:
BUSINESS ADDRESS: BUSINESS PHONE:
CITY: STATE: ZIP CODE:
APPLICANT SWEARS THAT ALL OF THE FOLLOWING ARE TRUE: NOTE:
(a) I am physically and mentally fit to handle explosives safely; Effective May 24, 2003, each applicant must list their ATF license or
(b) I am experienced in the use of explosives permit as applicable (Safety Explosives Act - November 25, 2002).
(c) I have not been convicted of a felony or misdemeanor involving the use of
explosives; Blaster certification expires every three years.
(d) I am of good moral character;
(e) I am not addicted to narcotic drugs or intemperate in the use of alcohol; You must submit this form 60 days prior to your expiration date.
(f) That I have read the Montana Blaster Certification Manual and am familiar
with the contents therein; The Department will notify you shortly concerning examination
(g) The statements made in this application are true. information, if applicable.
APPLICANT'S SIGNATURE: DATE:
Coal Blaster Certification Form (06/12) - Page 1 of 1
