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2. REQUEST FOR FIREWORK DISPLAY APPLICATION/PERMIT

   In accordance to NFPA 1123/1126- Penal Law 405 & 270

4. Sponsoring Organization:*
6. Date*
   Date
8. First Name*
9. Last Name*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Display Company:
19. Name*
21. Address*
23. City*
24. State*
25. Zip Code*
27. Phone Number*
29. NYS License*
30. ATF Federal License*
32. Emergency Contact
34. First Name*
35. Last Name*
37. Phone Number*
39. Operator
41. First Name*
42. Last Name*
44. Age*
45. Certificate number/expiration*
47. Assistant
49. First Name
50. Last Name
52. Certificate number/expiration
54. Display Information
56. Date*
    Date
58. Time Loading of Display*
    Time Loading of Display
59. Location Loading of Display*
61. Display Time*
    Display Time
62. Expected Duration*
64. Display Location
66. Address*
68. City*
69. State*
70. Zip Code*
72. Storage prior to display
74. Address*
76. City*
77. State*
78. Zip Code*
80. Rain Date
    Rain Date

    Rain Date
82. Please attach the following information with application:
    • Application for Operating Permit
    • Site Plan for display and fallout area
    • Certificate of Worker’s Compensation Insurance
    • Certificate of Insurance Coverage
    • Copy of Federal License/Permit (FEL)
    • Copy of State of New York Department of Labor-License to Deal in or Manufacture Explosives
    • Copy of Pyrotechnician Licenses
    • Display Content of Show:

84. I attest that the information contained in this permit application is accurate, true and complete to the best of my knowledge, and I understand that false statements made in this permit application are subject of applicable versions of the 

    NYS PENAL LAW. 

86. Applicant *
87. Signature of Permitting Authority*
Leave This Blank:


89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit

* indicates a required field