Firework operator initial application

Firework operator initial application
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
Evidence of Experience

(List participation in at least five fireworks displays --one of which must be within the last year. When applying for both Outdoor and Proximate Certificate, experience in a least five displays must be provided for each certification.)
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*
References
First Name* Last Name* Street Address* Address Line 2* City* State* Zip* Email*
First Name* Last Name* Street Address* Address Line 2* City* State* Zip* Email*
First Name* Last Name* Street Address* Address Line 2* City* State* Zip* Email*
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
Make checks payable to:
Minnesota State Fire Marshal Division
Attn: Fireworks Operator Certification Program
445 Minnesota Street, Suite 145
St. Paul, MN 55101-5145

All data required on a fire works operator certificate application is required by law or administrative rnle. 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.
Please verify that you are human*
Should be Empty:

Firework operator initial application

Evidence of Experience

References

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.