Fireworks operator display report

Fireworks operator display report
MSS 624.22, Subd. 6 requires fireworks display operators to report all displays to the State Fire Marshal within 30 days of the display. If an injury, fire over $100, or damage over $100 to property occurs, or unsafe or defective pyrotechnic products or equipment was used, return to the State Fire Marshal Division within 10 days of the display.
DISPLAY INFORMATION
Name of operator*

First NameLast Name
Email*
example@example.com
Pyrotechnic company email, if applicable
example@example.com
Certificate number*
Type of display*

NFPA 1123NFPA 160/1126
Date of display*

MonthDayYear
Date
Name of sponsoring organization*
Location of display*

Street Address

Street Address Line 2

CityState

Zip Code
County of display*
Permit issued by*

Fire DepartmentCounty SheriffOther
Defective Products/Injury/Damage
Was an unsafe or defective device product used or observed during the display?*

YesNo
Type of defective product*

MineAerial shellsRoman candlesSet piecesOther
Size of defective product*
Manufacturer*
Was there an injury as a result of the above display?*

YesNo
Name of injured*

First NameLast Name
Address of injured*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was there property damage or a fire resulting from the display?*

YesNo
Type of firework*
Cause of fire or damage*
Property description*
Estimated dollar loss*
I verify that the above information is true and accurate. I am aware that any false statement constitutes fraud and may result in a revocation of my certificate.
Signature*

Clear
All data required on a fireworks operator certificate application is required by law or administrative rule. The information is used to identify your fireworks operator certificate record and determine your eligibility for a fireworks operator certificate. Failure to provide required information may result in denial of the certificate. All information on the Fireworks Operator Display Report is public and copies of the application or its information may be issued to anyone.
Please verify that you are human*
Should be Empty:

Fireworks operator display report

DISPLAY INFORMATION

Defective Products/Injury/Damage

I verify that the above information is true and accurate. I am aware that any false statement constitutes fraud and may result in a revocation of my certificate.