Office of Surface Mining

Application for E-Filing

                                                            Website: sscr.osmre.gov

 

You must submit a separate form for each Reporting Entity (company) you wish to register for electronic filing.

Company Name ........................  ___________________________________________________  

Delivery Address (For FedEx).. ___________________________________________________

Address cont’d ...........................  ___________________________________________________

City ..............................................  ___________________________________________________

State .............................................    ____   ZIP ___________________

Contact Name ...........................  ___________________________________________________

Contact Phone ...........................  ___________________________________     Ext___________

E-mail address ...........................  ___________________________________________________

 


This computer system, including all related equipment, networks, and network devices (including Internet access), is provided by the Department of the Interior (DOI) in accordance with the agency policy for official use and limited personal use. All agency computer systems may be monitored for all lawful purposes, including but not limited to, ensuring that use is authorized, for management of the system, to facilitate protection against unauthorized access, and to verify security procedures, survivability and operational security. Any information on this computer system may be examined, recorded, copied and used for authorized purposes at any time. All information, including personal information, placed or sent over this system may be monitored, and users of this system are reminded that such monitoring does occur. Therefore, there should be no expectation of privacy with respect to use of this system. By logging into this agency computer system, you acknowledge and consent to the monitoring of this system. Evidence of your use, authorized or unauthorized, collected during monitoring may be used for civil, criminal, administrative, or other adverse action. Unauthorized or illegal use may subject you to prosecution
.                                        

I acknowledge receipt of the user identification and password and understand that I am responsible for the protection of this information. I understand that I am responsible for any transactions made with the use of my identification and password and will not divulge them to anyone.  If I know or suspect that my identification or password has been misused, divulged, or compromised, I will report this immediately to the System Security Officer, (303) 236-0330 Ext. 248.

 

Company Authorizing Signature _____________________________      Date: ____________________

 

Note:   Applicant Company must complete all items.  Any blanks will be cause for application rejection.

Please complete and mail to:                            Office of Surface Mining
                                                                                Attn: FACB
                                                                                PO BOX 25065
                                                                        Denver, CO 80225-0065                                                                                            1-800-799-4265, ext 325                                                       Fax:  303-236-8263

For OSM use only

User ID Assigned: ..............   __________________________         Reporting Entity #: ___________________        

Approved By: ....................   __________________________         Date Approved: _____________________        

Account Created by: ........   __________________________         Date Created: _______________________        

*720 IRS: ...........................   __________________________         Date Added:    ______________________

 

Page Last Modified/Reviewed: 6/2/14