8 ‐H o u r R e f r e s h e r This eight hour course complies with MSHA 30 CFR 48.28, which requires eight hours of annual

training for independent contractors and grantees in metal/non‐metal surface mines.

2 4 ‐H o u r N e w M i n e r This three‐day course complies with MSHA 30 CFR

48.25, which requires 24 hours of New Miner training for independent contractors and

grantees in metal/non‐metal surface mines.

8:00 am ‐ 4:30 pm | $100.00 per person | Rm L224

D a t e s May 4 June 1 June 22 May 18 June 15 June 29

8:00 am ‐ 4:30 pm | $300.00 per person | Rm L224

D a t e s

May 19, 20, 21 June 16, 17, 18

218-733-7650 (MSR/TTY)

M S H A S A F E T Y T R A I N I N G

MAY ‐ JUNE 2020 Multiple courses offered every month by LAKE SUPERIOR COLLEGE’ CUSTOMIZED TRAINING. 

LIVE ONLINE INSTRUCTION

REGISTER ONLINE at lsc.edu/training or complete a ached registra on form. Register by phone: Lake Superior College Customized Training 218-733-7680

Changes to exis ng registra ons, including cancella ons, will be accepted un l 12:00pm one business day (Mon, Tue, Wed, Thur, Fri) prior to the first date of an MSHA class. No refunds will be issued a er this date.

COURSE REGISTRATION FORM | May - June 2020

Live Online | MSHA (Mine Safety & Health Administra�on) Con�nuing Educa�on & Customized Training (CECT) 2101 Trinity Road, Suite 2060; Duluth, MN 55811

Registra�on ques�ons, email them to workforce@lsc.edu. MSHA course ques�ons, email Leonard Johnson at leonard.johnson@lsc.edu.

Course Descrip�ons These two Live Online MSHA courses provide safety training requirements to meet New Miner, Experienced Miner and Annual Refresher as required for independent contractors and grantees in metal/non-metal surface mines. New Miner and Experienced Miner courses will be required to receive a mine/site tour before the par�cipants MSHA 5000-23 Form can be completed and before the employee can work at an MSHA regulated site or mine (Sept. 2017) as part of the required “Introduc�on to Work Environment.” In addi�on, Lake Superior College (LSC) can provide MSHA training to sand and gravel opera�ons for those companies that incorporate Lake Superior Colleges training tasks within their own MSHA submited training plan. Call Leonard Johnson at 218-733-1079 with ques�ons you may have about this course.

COURSE SELECT COURSE BY CHECKING ONE OF THE DATES BELOW:

COURSE DAY(S) COURSE TIME

COURSE COST

8 HOUR REFRESHER MSHA 30 CFR 48.28

May 4 May 18 June 1 June 15 June 22 June 29

Monday Monday Monday Monday Monday Monday

8:00am - 4:30pm

$100.00

24 HOUR NEW MINER MSHA 30 CFR 48.25

May 19, 20, 21 June 16, 17, 18

Tues., Wed., and Thur. Tues., Wed., and Thur.

8:00am - 4:30pm

$300.00

Once registered for a Live Online MSHA offering, course instructions will be emailed out prior to course start. Ensure you provide BOTH the PARTICIPANT’s EMAIL ADDRESS and PHONE NUMBER to ensure all course instructions and updates related to course reach person attending our training.

CAMPUS and ADDRESS BUILDING and ROOM

Lake Superior College’s Main Campus | 2101 Trinity Road | Duluth, MN 55811 Virtual Online Classroom

Company Informa�on

MSHA Iden�fica�on Number _________________________________________________________________________ Note 2: Provide your MSHA Identification Number (Mine or Contractor / Company).

Company Name _____________________________________________________________________________________

Company Address ___________________________________________________________________________________

Company City ______________________ Company State __________________ Company Zip __________________

Company Phone ___________________________________ Company Email _________________________________

Course Par�cipants Personal Informa�on

First name ______________________ Middle name ___________________ Last name ______________________ Note 1: MSHA (A division of the Federal Department of Labor) requires your full legal name. If you do not have a legal middle name, note as N/A).

Birthdate _____________________________ Last 4 digits Social Security# __________________________________

Home address ____________________________________________________________________________________

Home City ________________________ Home State ____________________ Home Zip ____________________

Personal Cell Phone _________________________________ Home Phone _________________________________

Personal Email ___________________________________________________________________________________

Have you registered at LSC Before? __ No, __ Yes, If Yes provide Student ID#____________________________

Birthdate ____________________________ Last 4 digits Social Security# ____________________________

Race and Ethic Background Gender Check or circle any that apply below: Check or circle below:

American Indian, Alaska Na�ve, Asian, Black or African American, Hispanic or La�no, White, or Unknown

Male Female

Registra�on Op�ons Notes:

Do not email if registra�on form if contains credit card or other sensi�ve informa�on; use alternatesubmission methods: by phone, or online as outlined below.

Register online. Phone in registra�on form details to 218-733-7680. Registra�ons or changes to exis�ng registra�ons, including cancella�ons, will be accepted un�l 12:00 pm

two business days prior to the first class. No refunds will be issued a�er this date.

Payment Op�ons Circle or check one op�on below:

Cash

Invoice. Provide company name to issue invoice: _____________________________________________________

Check. Provide check # enclosed: ______________________________ (Make checks payable to Lake Superior College.)

Contracted. Course payment by terms as outlined within Contract.

Credit Card. Contact Registrar at 218-733-7680 to process registration and credit card by phone.

Payment Receipt Circle or check “Yes” if you wish to receive a course payment receipt, or “No” if you do not require a payment receipt.

Yes. Provide payer’s email address to send electronic receipt to: ________________________________________ No

Disability Coordinator Individuals with a documented disability may request reasonable accommodations from the LSC Disability Coordinator at 218-733-7650 (voice) or 800-627-3529 (MSR/TTY).

Tax Deduc�bility No�ce Classes may be tax deductible under Hope Scholarship and Life-Long Learning tax laws. Your social security number must be provided to claim either of these deductions. Many colleges/universities use social security numbers for student identification purposes on student records. Providing your social security number, birth date, gender, and ethnic background is voluntary. If you do not provide this information, your application will still be processed. This data is requested for purposes of administration, program evaluation, and consumer and alumni data. The data may also be used to create summary information about MNSCU programs through data matches with other state agencies.