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2. 
3. FIREWORKS DISPLAY LICENSE APPLICATION
5. First Name*
6. Last Name*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Telephone*
15. Email
17. Date of Birth*
18. Place of Birth*
20. Driver's License #*
21. State*
23. Place the Event will take Place*
25. Date(s) of Fireworks Display*
26. Hours of Fireworks Display*
28. Location Pyrotechnics will be Activated*
30. Name of Person/Business for Pyrotechnics*
31. Individual in Charge of Recovering Unfired Pyrotechnics*
33. Number/Kind of Pyrotechnics Being Used*
35. Location Pyrotechnics will be Store until the Event*
37. Signature*
38. Date*

42. Attach the Following Items:

44. A diagram of the area where the display will take place showing the firing area, distances to the audience, to buildings, to roadways and public pathways, and special conditions*
46. Declaration page of insurance policy showing liability coverage.*
50. City Manager Approval
51. Date
53. Application Received By
54. Diagram Received By
56. Permit to Process & Display Fireworks Received By
58. Referred to Fire
59. Date to Fire
60. Referred to PD
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field