Change of Address request

VA Department of Mines, Minerals and Energy
Division of Mines
Coal Miner Certification Records

Change of Address Request

Use this form to update your mailing address in our records.

NOTICE: This information cannot be changed without all data and a correct date of birth.

Your full name:

Your Date of Birth:	(mm/dd/yyyy)
Your Phone Number:

Your Old Address:

Street

City State Zip Code

Your New Address:

Street

City State Zip Code

Your email address: (optional)