Fireworks operator renewal application

Fireworks operator renewal application
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 application is public and copies of the application or its information may be issued to anyone.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Driver's license #*
Date of birth*

MonthDayYear
Date
Certification number*
Expiration date of certification*

MonthDayYear
Date
Evidence of experience

List three fireworks displays for each renewal category in which you participated during the past four year certification period.
Date* Street Address* Address Line 2* City* State* Zip* NFPA 1123 NFPA 160/1126*
Date* Street Address* Address Line 2* City* State* Zip* NFPA 1123 NFPA 160/1126*
Date* Street Address* Address Line 2* City* State* Zip* NFPA 1123 NFPA 160/1126*
Date Street Address Address Line 2 City State Zip NFPA 1123 NFPA 160/1126
Date Street Address Address Line 2 City State Zip NFPA 1123 NFPA 160/1126
Date Street Address Address Line 2 City State Zip NFPA 1123 NFPA 160/1126
Have you been convicted of a felony, gross misdemeanor, or misdemeanor involving fireworks or explosives?*

YesNo
Have you caused or permitted a fire or safety hazard to exist or occur during the storage, transportation, handling, preparation or use of fireworks?*

YesNo
Have you conducted a fireworks display without receipt of a permit required by the state or political subdivision?*

YesNo
Have you conducted a display of fireworks with assistants who were not at least 18 years old, properly instructed and continually supervised?*

YesNo
If you answered yes to any of these questions, attach documentation with explanation.*

Cancelof
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 certification.
Signature*

Clear
The $100.00 renewal fee (check or money order only) must be included with the application. Make checks payable to:

Minnesota State Fire Marshal Division
Attn: Fireworks Operator Certification Program
445 Minnesota Street, Suite 145
St. Paul, MN 55101-5145
Please verify that you are human*
Should be Empty:

Fireworks operator renewal application

Evidence of experience

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 certification.