Blasting Certification Application

   Account Changes
*All fields are required


 

 
Specify type work:

First Name:
 

Last Name:
 

Race:


Gender:  

Date of Birth:
 

Social Security Number:
   

Phone:
   

Email Address:
 

Renewal Email Address:
    Renewal reminders will be sent to this address.

Mailing Address:
 

City, State, Zip:
     

Employer:
 

Employer Address:
 

City, State, Zip:
     

Employer Phone:
 

1) Have you ever been certified or licensed by this office before?  

Please submit at least two(2) years of work experience.

Previous Employer:


Type of Blasting:


Previous Employer Address:


City, State, Zip:


Previous Employer Phone:


From:


To:



2) Are you currently certifed and licensed in any other state?  

Upload Certificate from another state:
(Files must be in PDF format)

3) Have you ever been denied a blaster's license in any state?  
Details:

4) Has this blaster ever been charged with or convicted of a crime involving the illegal use of explosives?  

Details:

5) Are you under indictment or information for, or have you been convicted in any court of, a crime punishable by imprisonment for a term exeeding one(1) year or a felony? (Charges may include, but are not limited to, crimes involving drugs, burglary, robbery, murder, manslaughter, and explosives or firearms violations.)  


6) Are you a fugitive from justice?  


7) Are you an unlawful user or addicted to the use of alcohol, narcotics or dangerous drugs?  


8) Have you ever been adjudicated mentally defective or committed to a mental institution?  

Details:

9) Are you a United States Citizen?  


10) Have you been discharged from the armed forces under dishonorable conditions?  

Details:

11) Have you ever renounced your United States Citizenship?  


12) Do you store explosives?  



Location of physical storage facility:


I hereby certify that the information provided herein is true and correct.