Licensee Signature Authorization Form

LICENSEE SIGNATURE AUTHORIZATION FORM

This is to notify the Office of Mine Safety and Licensing that any of the individuals listed below can sign any of the forms required for a mine license for the licensee listed below.

(Licensee) / (State File Number)
(Print or Type Name / (Social Security Number) / (Signature)
(Print or Type Name / (Social Security Number) / (Signature)
(Print or Type Name / (Social Security Number) / (Signature)
(Print or Type Name / (Social Security Number) / (Signature)
(Print or Type Name / (Social Security Number) / (Signature)

Please be sure to notify your District Office if any of the above listed individuals are no longer approved to sign documents for your company.

Date: