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All data required on a fireworks 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 Fireworks Operator Display Report is public and copies of the application or its information may be issued to <br />anyone. <br />Revised 06/11 Page 1 <br /> <br />DEPARTMENT OF PUBLIC SAFETY <br />MINNESOTA STATE FIRE MARSHAL DIVISION <br />FIREWORKS OPERATOR DISPLAY REPORT <br /> <br />MSS 624.22, Subd. 6 requires fireworks display operators to report all displays to the State Fire Marshal within 30 days of the display. If <br />an injury, fire over $100, or damage over $100 to property occurs, or unsafe or defective pyrotechnic products or equipment was used, <br />complete Part B and return to the State Fire Marshal Division within 10 days of the display. <br />PART A – DISPLAY INFORMATION <br />Name of Operator Certificate Number <br />Type of Display: ( ) Outdoor ( ) Outdoor Proximate Audience ( ) Outdoor Both ( ) Indoor Proximate Audience <br />Display Date: Display Time: From To <br />Sponsor (Private individuals may not sponsor a display) <br />Outdoor and Outdoor Proximate Audience Display Information <br />Name of Property or Address where Display Occurred <br />City / Township County <br />Required for Indoor Proximate Audience Displays <br />Name of Facility where Display Occurred <br />Address City County <br />Assistants: Name Date of Birth MN Fireworks Operator Cert. # (If Applicable) <br /> <br /> <br /> <br /> <br />Attach separate sheet for more assistants, if necessary. <br />Defective Products/Injury/Damage <br />Was an unsafe or defective device product used or observed during the display? ( ) Yes ( ) No If yes, answer Part B, Section I. <br />Was there an injury as a result of the above display? ( ) Yes ( ) No If yes, answer Part B, Section II. <br />Was there property damage or a fire resulting from the display? ( ) Yes ( ) No If yes, answer Part B, Section III. <br />If you answer yes to any of these questions complete and return page 2. <br />I verify that the above information, and that attached information on page 2 if necessary, is true and accurate. I am aware <br />that any false statement constitutes fraud and may result in a revocation of my certificate. <br />Signature: Date: <br />Return this form to: Minnesota State Fire Marshal Division <br />Attn: Fireworks Operator Certification Program <br />444 Cedar Street, Suite 145 <br />St. Paul, MN 55101-5145