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Pyrotechnic Special Effects and/or Display Fireworks Permit

APPLICANT MUST BE THE PERSON SUPERVISING THE FIRING OF THE FIREWORKS

Please selected which permit you are applying for:

Pyrotechnic Special Effect Fireworks Permit ($171)

Display Fireworks Permit ($171)

Applicant Information:

Name:

Address:

Telephone:

Fax

Email Address

Company Name:

Fireworks Supervisor Card No:

Copy of Supervisor Card

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Date of Event:

Time of Event:

Location:

Launch Site:

Name of Property Owner:

Address of Owner:

Name and Address of Sponsoring Agency: