NORTHSHORE TECHNICAL COMMUNITY COLLEGE - MSHA 48 (Mar 2026)

Please provide the information requested below. This information will be used to register the employee in the training.

Employer Name
Employer Contact
Employer Contact Email
Employer Contact Phone Number
Complete the following information for the employee who is enrolling in the class.
Employee's Last Name
Employee's First Name
Email Address
Phone Phone - ### - ### ####
Street Address
City
State
Zip Code
Parish
Country
ARE YOU A U. S. CITIZEN?

ARE YOU A U. S. CITIZEN? YES NO
Residency

Residency R-Louisiana resident O-Out of State
Date of Birth Date of Birth / MM / DD YYYY
Social Security Number
Gender

Gender Male Female
Race/Ethnicity

Race/Ethnicity American indian or Alaska Native Black or African American Caucasian/White Asian Native Hawaiian or Other Pacific Islander Hispanic or Latino
SELECT THE TRAINING BELOW:
Part 48 Class location-231 West Cornerview Street, Gonzales, LA 70737

Part 48 Class location-231 West Cornerview Street, Gonzales, LA 70737 Part 48 Annual Refresher 1-day (March 19, 2026) 7:30am - 4:30pm Part 48 New Miner 3-day (March 16-18, 2026) 7:30 am - 4:30pm
IMPORTANT INFORMATION
Cost of training Part 48 New Miner: $300.00 Cost of training Part 48 Annual Refresher: $100.00 Cost will be invoiced to employer. Please Call Robin Sharkey at 985-545-1707 to inquire about a specialized date.