Fireworks Display Permit Application

Purpose: This form is required to obtain legal authorization for conducting a fireworks display, whether for public spectacle or private celebration. All necessary information must be accurately completed for review and approval by the appropriate local authority.

Applicant Information

Organization/Individual Name: {applicantName}

Contact Person: {contactPerson}

Phone Number: {phoneNumber}

Email Address: {email}

Mailing Address: {address}

Display Details

Type of Event: {eventType}

Date of Display: {eventDate}

Time of Display: {eventTime}

Rain Date: {rainDate}

Display Location: {displayLocation}

Expected Attendance: {expectedAttendance}

Fireworks Details

Fireworks Operator Name: {operatorName}

Operator License Number: {operatorLicense}

Company Providing Fireworks: {fireworksCompany}

Types of Fireworks to be Used:

{#fireworksTypes}

• {type}

{/fireworksTypes}

Safety and Security

Safety Officer Name: {safetyOfficer}

Emergency Services Notified: {emergencyServices}

Fire Extinguishers Onsite: {fireExtinguishers}

Distance from Audience: {distanceFromAudience}

{#hasInsurance}

Insurance Provider: {insuranceProvider}

Policy Number: {policyNumber}

Coverage Amount: {coverageAmount}

{/hasInsurance}

{^hasInsurance}

No insurance coverage provided.

{/hasInsurance}

Required Permits / Documents Attached

{#documentsAttached}

• {documentName}

{/documentsAttached}

Persons Assisting in the Display

Agreement and Signature

I, {contactPerson}, acting on behalf of {applicantName}, certify that the information provided above is accurate to the best of my knowledge. I acknowledge full responsibility for compliance with all safety regulations and local laws pertaining to this fireworks display, and agree to hold harmless the jurisdiction issuing this permit.

Signature: ____________________________

Date: {submissionDate}