Membership | MineSafetyConference

Conference Membership

Want to join the team?

We want safety crazy people to join the team.

Membership Application

Committee Member Application Form Mine Safety and Health Conference

First Name

Work Email

Last name

Work Phone

Company Information

Company Name

Title

Street Address

City

Postal / Zip code

Street Address Line 2

Region/State/Province

1. Does your company have a registered MSHA Mine / Contractor ID?

Yes

2. Have you ever attended the Mine Safety and Health Conference?

Yes

If yes, how many?

3. Membership in other Professional Organizations / Conference (Please list Organization Name and Contact Information):

4. Brief Autobiography (Also, please Attach Resume):

Upload Resume

Upload File

5. What skills / experiences can you contribute to the Mine Safety and Health Conference Planning Committee?

6. Please rank in order 1-3 your top choices for subcommittee selection. (This is only a preference and cannot guarantee assignment will be to choice listed below)

7. Do you currently know / affiliated with a current Mine Safety and Health Conference Committee Member? If so, please provide name here:

Select a date

Your Signature

Thank you for your application!

Contact Sara Nichols

If you prefer to download the form, use the link provided. Send completed forms to Sara Nichols.

Any questions, also send to Sara Nichols.