Required fields are marked with asterisks (*)

Fireworks & Pyrotechnics Event Application Form

(Special Events Application - Appendix C)

A. Applicant Information

Organization Name

Contact Name

Prefix

Mr.

Ms.

First Name

Last Name

Organization Address

Number

Street Name

Suite No.

City

Province

Postal Code

Contact Information

Primary Phone

Ext.

Fax

Emergency Phone

E-Mail

B. Supervisor Information

Contact Name

Prefix

Mr.

Ms.

First Name

Last Name

Address

Number

Street Name

Province

Postal Code

Contact Information

Primary Phone

Ext.

Fax:

Emergency Phone

E-mail:

Certificate Information

Certificate Number:

Class:

Expiry:

C. Company Information

Company Name

Company Address

Number

Street Name

Suite No.

City

Province

Postal Code

Contact Information

Primary Phone

Fax:

D. Pyrotechnic Event Information

Start Date & Time

End Date & Time

Date:

Time:

E. On-Site Pyrotechnic Storage

Please note the location and method of on-site pyrotechnic storage:

F. Application Checklist

Please attach the following documents to the completed application:

List of Fireworks/Pyrotechnics to be used

Event Description (Firing Order)

Certificate of Insurance

Site Plan Diagram

Fire Safety Plan

G. Signature

Signature of Pyrotechnician

Clear

Date:

Signed By: