Example of photo caption... Another caption... Example of photo caption... Another caption...

Indiana Coal Miner Registration Form

Back to Coal Miners page

            Browse the Registry Database

 
Last Name                                    * required field
First Name                                    * required field
Middle Name
Street Name
Street Number
City
State
Phone Number (xxx-xxx-xxxx)
E-Mail Address
Birth Date and Year Day Month Year
Birth Place
Spouse or Closest Living Relative
Maiden Name
Name of the Coal Company(Companies)
Where Employed
Siblings or Relatives Engaged in Coal Mining
Coal Mines Owned
Please List and Indicate Location

 Coal Mine Name   Location
 Coal Mine Name   Location
 Coal Mine Name   Location
Please List Coal Mines and Jobs Held
with Dates of Employment

Coal Mine NameJob Title
                From Year To Year

Coal Mine Name Job Title
                From Year To Year

Coal Mine Name Job Title
                 From Year To Year
Please List Mining Certificates Held
Comments