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All data required on a fire works operator certificate application is required by law or administrative rule. The information is used to identify your fireworks <br />operator certificate record and determine your eligibility for a fireworks operator certificate. Failure to provide required information may result in denial of <br />the certificate. All information on the application is public and copies of the application or its information may be issued to anyone. <br /> <br />Revised 1/04 <br />DEPARTMENT OF PUBLIC SAFETY <br />MINNESOTA STATE FIRE MARSHAL DIVISION <br /> <br />FIREWORKS OPERATOR CERTIFICATION APPLICATION <br /> <br /> <br />(Please print or Type) <br />Name: <br /> <br />Address: City: <br /> <br />State: __________ Zip: Telephone: (H) (W) <br /> <br />Fax Number: E-mail Address: <br /> <br />Driver's License Number: State: Date of Birth: <br /> <br />Certification Applied For: _____Outdoor Display _____Proximate Display _____Outdoor and Proximate Display <br /> <br />Office Use Only <br />Name on Check:_______________________________Amnt:__________________ <br />Picture ID: Yes