PENNSYLVANIA PERMIT APPLICATION            

PERMIT FOR PURCHASE AND DISPLAY OF CONSUMER FIREWORKS                   
AS PERMITTED BY 35 P.S. 1275.2                    
  


This Permit authorizes the Applicant ___________________________________________________________,

to purchase consumer fireworks from __________________________________________________________,

for the display of consumer fireworks at _________________________________________________________

_______________________________________________________________________________________

________________________________ ; ____________________________________________ County, PA.

The date for this consumer fireworks (1.4g) display event is _________________________________________

which shall not be less than three days from the date of delivery of this Permit to the retailer of consumer fireworks. 

The grant of this Permit is a non-transferrable privilege, which is valid only for the date identified as the consumer

fireworks display event day.  The applicant agrees that he or she will fire or discharge the consumer fireworks as

or with a competent operator, and that the consumer fireworks display will not be hazardous to property or

endanger any person or persons.  The applicant releases the Municipality and retailer of the consumer fireworks

from liability, losses and/or claims, which may arise from the display of consumer fireworks.





BY:_________________________________________________  Date:______________________________
        Signature of Municipal Officer

      _________________________________________________            ______________________________
        Printed Name of Municipal Officer                                                                Title of Municipal Officer

      _________________________________________________             ______________________________
        Daytime Telephone Number                                                                           Permit Number