Form 5000-46 Request for MSHA Individual Identification Number (MIIN)

Instructions for Completing the MSHA Individual Identification Number (MIIN)
MSHA Form 5000-46 (OMB Form 1219-0143)
This information is intended only for the individual named in this document. If you are not the intended recipient,
you are notified that use, disclosure, or distribution of the information is strictly prohibited and may be subject to

criminal sanctions. If you received this information in error, please notify the Mine Safety and Health Administration
Qualification and Certification Unit, P.O. Box 25367, Denver, CO 80225, locally in Colorado (303) 231-5472, toll free

(800) 579-2647, Fax (303) 231-5474, E-Mail to: [email protected]

Applying for and receiving a MIIN does not change your immigration status or your right to work in the United States.

Please print legibly
Personal Identification number (REQUIRED)
This will be your Social Security Number (SSN), Canadian Social Insurance Number (CSIN) for
Canadian citizens working in the United States, or Individual Tax Identification Number (ITIN), for foreign
nationals working in the United States that do not have an SSN. Wi thout the Personal Identification
Number MSHA will not be able to move your current qualifications or approvals to your new MIIN
number or issue a MIIN number to you.
Legal Name (REQUIRED)
First Name is required

Middle Initial
Last Name is required
Suffix (Jr., Sr., II etc.)
Mailing Address (REQUIRED)
This is the address where you would like to have your MIIN information mailed to.
Questions for Miner Validation - (REQUIRED)
Check one question only. Your selected question will be asked by MSHA personnel to validate that we
are speaking to the actual MIIN holder when you call to request your records or to make changes. You
must remember your selected question .
Answer to question - (REQUIRED)
Supply a one word answer to the question you have selected.
MSHA will ask the question you have selected and you will supply the answer to the question. You
must remember your selected answer.
Signature - (REQUIRED)
Date - (REQUIRED)
Return Form to:

Mine Safety and Health Administration
Qualification and Certification Unit
P.O. Box 25367, DFC
Denver, CO 80225

Fax: 303-231-5474

Mine Safety and Health Administration
Request for MSHA Individual Identification Number (MIIN) MSHA FORM 5000-46
This form is affected by the Privacy Act of 1974.

Approved for use through 05/31/2017

OMB Number 1219-0143

The Mine Safety and Health Administration (MSHA) will issue a MSHA Individual Identification Number (MIIN) to persons seeking qualifications and/or
certification under 30 CFR Part 48, Part 70, Part 71, Part 75.00, 75.153, 75.155, Part 77.100, 77.103, 77.104, 77.105 and Part 90. Completion of this form is
mandatory, as this number will be used for all applications for certifications or qualifications and will also cover any prior certification or qualification issued by
MSHA. This number will be used for all occurrences of training or applications to MSHA that are submitted by the mining operator, instructor, State, or
person applying to be an MSHA approved instructor. Once MSHA receives this request, a MIIN will be mailed to the address provided below. This number
must be used when applying for or receiving qualifications or certifications and when contacting MSHA for questions or corrections of information. This
number will also be used to identify miners who have exercised their option to work in areas of a mine with respirable dust concentration at or below .5
milligrams per cubic meter of air under 30 CFR Part 90. Information on this form will be kept confidential to the extent allowed by the law.
Instructions for this form contain further info rmation on the need and use of this form.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data 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 and Health Administration, U.S. Department of
Labor, Office of Standards, Regulations and Variances, 201 12th Street South, Suite 401, Arlington, Virginia 22202-5452. Persons are not required to
respond to this collection of information unless it displays a currently valid OMB Control Number.

Please read the instructions before entering information on the form
Please print

Personal Identification Number

Type of ID SSN

CSIN

ITIN

Legal Name:
First
Name

Middle
Initial

Last
Name

Suffix

Mailing Address:
1st Street
2nd Street
City

State

Zip Code

Country
Questions will be used for personal validation. Select one question that MSHA may use to validate that we are speaking to the actual MIIN
holder:
Select check box for question to be answered, use a single word answer for selected question
1. What is your grandfather's first name?
2. What is the name of the city/town you were born in?

Answer

3. What was the model of your first vehicle?
4. What is the name of your favorite sports team?
5. What was your first pet's name?
False certification is punishable under section 110(a) and (f) of the Federal Mine Safety and Health Act (PL91-173 as amended by PL 95-164)

Signature

Date

For questions on this application, please contact the Q & C Unit (303) 231-5472 or (800) 579-2647, Fax (303) 231-5474, E-Mail to:
[email protected]
Return Form to:

Mine Safety and Health Administration
Qualification and Certification Unit
P.O. Box 25367, DFC
Denver, CO 80225

MSHA Form 5000-46, Aug. 2015 rev. (Mailing Address)