We (Company/Organization/Individual)

hereby make application for a permit to conduct a public

Display of Fireworks on (mm-dd-yyyy)

Display to be held at

Firm and address of company providing fireworks

Bond amount($1,000.00 or more)

Payment Type

Has liability insurance been obtained?

All accidents must be reported to the Office of the State Fire Marshall within thirty-six hours of occurrence.

Email

Signature

Click here to sign

*Application is to be submitted to appropriate local authority (City Councils in cities, the President and Boar of Trustees in villages and incorporated towns, and outside the corporate limits of cities, villages and unincorporated towns, the County Board.)

**The form and amount of the bond is to be determined by the local authority, so long as it is not less in amount than $1,000.00 and conditioned upon compliance with the Fireworks RegulationAct and the Rules of the State Fire Marshall. It can be a personal bond without sureties.