District 3 Out-of-Work Notification Form This registration is good for 140 days only Name: *required Registration Number: *required Street Address: *required City: *required State: *required Email Address: *required Phone: *required Phone 2: My job with: *required Ended on: (xx/xx/xxxx) *required Check box if you worked less than 40 hours Please check your Certifications/Training MSHA Part 46 Certified OSHA 10 Hr. CDL License A OSHA 30 Hr. CDL License B IUCSAT CCO Small Hydraulic Hazmat Trained CCO Large Hydraulic Forklift Certified CCO Lattice Boom Crawler Pipeline Certified CCO Lattice Boom Truck Carrydeck Certified CCO Tower Crane MICCS Please check all classifications for which you would like to be called Air Compressor Air Tugger Asphalt Plant Engineer Asphalt Transfer Machine (shuttle buggy) Assistant Plant Engineer Assistant to Engineer Auto Grade or similar machine Automatic Dry Batch Plant Backhoe Backfiller Base Paver (Jersey or similar type) Belt Spreader Bending Machine (power-driven) Bituminous Distributor Bituminous Mixer Bituminous Patching Tamper Bituminous Paver Bituminous Plant Engineer Boiler Boom Cat Boring Machine Broom & Belt Machine Bull Dozer Bull Dozer (finish) Caisson Drilling Machine Carry Deck Cherry Picker Chip Spreader (self propelled) Coleman Type Screen Compactor or Tamper (self-propelled) Compactor with Bull Dozer Concrete Belt Pacer (formless) Concrete Curing Machine Concrete Finishing Machine/Bull Float Concrete Mesh Depressor (independent) Concrete Plant Concrete Pump Concrete Saw Concrete Spreader (power-driven) Concrete Tinning or Broom Machine (formless) Core Drilling Machine Conveyor (portable) Crane Class 40 Hr. (Oiler) Crane (electric overhead) Crane Hydraulic Telescoping with all attachments Crane Lattice Boom with all attachments Curb Barrier Wall Machine CMI Type Curb Machine Derrick Ditching Machine Dredge Operator / Engineer Drilling Machine Earthmover Elevator inside (push button-type) Excavator Farm Tractor all attachments Foreman Fork Lift Machinery Fork Lift Masonry and Material Form Grader Form Tamper (motor driven) Formless Paver Generator Gradall Grader Grader (finish) Gravel Processing Plant (portable) Greaser Helper Gunite Machine Haul Units Head Greaser Helicopter Crew Hoist (material & personnel) Horizontal Directional Drill Hydra Seeder Hydraulic Boom Truck Hydro Demolition Equipment Hydrohammer Jacks (hydraulic power driven) Loader (rubber tire) Loader (track) Locomotive Mechanical Heater Mechanic (jobsite or shop) Mechanics Helper Milling Machine Mesh or Steel Placer Multiple Tamping Machine (RR) Oiler Guardrail Post Driver Outboard or Inboard Motorboat Panel Board Concrete Plant Paver (Hetherington) Paver Micro Surface Paving Breaker Paving Joint Mac Pile Driver Post Hole Digger Power Broom (self propelled) Pug Mill Pull Broom (power type) Pull Grader (power control) Pump Push Cat Rock Crushing Plant Roller (asphalt) Roller (earth) Roller with Dozer Blade Root Rake Tractor Mounted Sand Blaster Vacuum Scoop & Tractor Scraper (rubber tired) Seaman Tiller Self-Propelled Widener Sheepfoot Roller (self-propelled) Shop Mule Skid Steer Slurry Seal Machine Spreader Box Stripping Machine, Paint (motor driven) Straddle Carrier (Ross type) Straw Blower or Brush Mulcher Stump Remover (tractor mounted) Sub Grader Surface Heater and Planer Tamper (multiple vibrating) Tandem Push Tractor Throttle Valve Throttle Valve and Air Compressor Tiller Tower Crane Tractaire Tractaire with Drill Tractor Mounted Spreader Tractor with Winch Tree Mover Trench Box Trench Machine Truck Crane Oiler/Driver Tube Float Tunnel Shield Vacuum Machine Water Pump Water Wagon Welder Well Drilling Machine Well Point System Widener ( APSCO or Similar) Winch Truck Laser GPS Global Positioning System Distribution Enter the characters shown in the above image [0-9, A-F]: not case sensitive            Press only one time and wait for confirmation

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