Office of Surface Mining
Website: sscr.osmre.gov
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
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