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2. Operator Fireworks Display Information

   Please complete all fields for the individual, group, or organization operating the fireworks display.

4. Name
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Fax Number
18. Fireworks Supplier Information

    Please complete all fields for the fireworks supplier.

20. Name
21. Email Address
23. Address
25. City
26. State
27. Zip Code
29. Phone Number
30. Fax Number
34. Firework Information*

    Please enter an inventory of the type and quantity of fireworks, the expected length of the proposed display, and the date of the show.

36. Pyrotechnic Operator's Permit*

    Please submit a copy of the operator’s pyrotechnic operator’s permit, obtained from the State of Alaska, Department of Public Safety.

37. Fireworks Display Permit Application*

    Please submit a copy of the fireworks display permit application submitted to the State of Alaska, Department of Public Safety.

39. Fireworks Display Permit*

    Please submit a copy of the fireworks display permit obtained from, the State of Alaska, Department of Public Safety.

40. Site Plan*

    Please submit a site plan identifying the location of the proposed display, the location where fireworks will be used and stored, and the surrounding properties.

42. Financial Responsibility*

    Please submit evidence of the display sponsor’s and operator’s financial responsibility. This could take the form of an insurance certificate or other document attesting to coverage and responsibility.

43. Submittal Date & Time*
    Submittal Date & Time

    Submittal Date & Time

    Please enter the date and time of submitted application.

45. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature
51. FNSBC 21.16 Fireworks
    FNSBC 21.16 Fireworks

    Additional Firework Information:  Definitions (21.16.010), Sale Prohibited (21.16.020), Use Restricted (21.16.030), Firework Displays - Permit Required (21.16.040), Authorized Sale and Use (21.16.050), and Penalty for Violations (21.16.060)

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field