Mine Registration Application

The Great Seal of the State of New Jersey

Office of Public Safety Compliance

PO Box 386

Trenton, NJ 08625-0386

Telephone (609) 292-2096 Fax (609) 777-4589

Company Information
**
Name of the organization
**
Company ID number
**
(MM/DD/YYYY)
Date of application
**
Inspector's number
**
Number of hours for the inspection
**
Number of hours traveled
**
Type of operation code
**
Operation code
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Mailing address of applicant
**
Contact number of applicant
(333)333-3333

(** indicates a required field)

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