Release/Authorization Form

Click the button below for our display fireworks 1.3G release/authorization for pick-up or fill-out the form below.

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DISPLAY FIREWORKS 1.3G RELEASE/AUTHORIZTION FOR PICK-UP

The undersigned are aware of all the dangers of Fireworks and are willing to assume full responsibility for use of these products. The undersigned specifically agrees that he/she will not sue the seller for any claims that may arise from the use, storage, transportation or re-sale of the seller’s products. This release is executed freely and voluntarily by the undersigned for the purpose of protecting the seller from future potential liability. The undersigned understands and acknowledges the significance and consequences of such specific intentions to release any and all future claims against the seller.

WARNING: 1.3G DISPLAY FIREWORKS ARE EXTREMELY DANGEROUS!

The Bureau of Alcohol, Tobacco, Firearms & Explosives, The US Department of Transportation and State Authorities regulate the sale and use of Display Fireworks. These items are intended for use by licensed and experienced persons only. All persons coming in contact with these products must be warned of their inherent danger.

LICENSEE/PERMITTEE/GOVERNMENT ENTITY INFORMATION

NAME*
STREET ADDRESS* CITY* STATE* ZIP*
PHONE* FAX EMAIL*
SOCIAL SECURITY # OR FEDERAL TAX ID #*


PERSONNEL AUTHORIZED TO ORDER DISPLAY FIREWORKS

NAME*
STREET ADDRESS* CITY* STATE* ZIP*
BIRTH PLACE* BIRTH DATE*


PERSONNEL AUTHORIZED TO PICK-UP DISPLAY FIREWORKS

NAME*
STREET ADDRESS* CITY* STATE* ZIP*
BIRTH PLACE* BIRTH DATE*


INTENDED USE OF DISPLAY FIREWORKS

DISPLAY RESALE OTHER

YOU VERIFY THAT THE PROVIDED INFORMATION IS CORRECT.
CHECKING THE BOX TO THE RIGHT WILL ACT AS YOUR ELECTRONIC SIGNATURE.*
DATE*