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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 2 <br />PART B – INJURY/DAMAGE/DEFECTIVE PRODUCT INFORMATION <br />Section I – Defective Product <br />List all fireworks that were duds, malfunctioned, or defective. For each firework listed, the report shall include: Type of <br />firework (Type 1 - Mines, Type 2 - Aerial Shells, Type 3 - Roman Candles, Type 4 - Set Pieces), size of firework if <br />applicable (i.e., 6 inch shell.), and manufacturer’s name. (Use a separate sheet for additional defective products) <br />Firework Type (Type 1, 2, Etc.) Firework Size Manufacturer <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Section II – Injuries <br />Describe any injuries caused by fireworks. Each injury shall be listed separately, and shall include the type of firework <br />that injured the person, cause of the injury, type of injury, and the name, address, age and telephone number of the <br />injured person. (Use a separate sheet for additional injuries) <br />Firework Type: Cause of Injury: Type of Injury: <br />Injured Name: Address: City: State: Age: Telephone: <br />Firework Type: Cause of Injury: Type of Injury: <br />Injured Name: Address: City: State: Age: Telephone: <br />Section III – Property Damage <br />Describe any fires or property damage (over $100) caused by fireworks authorized by the permit. Each fire/damage shall <br />be listed separately and shall include the type of firework that started the fire/damage, cause of the fire/damage, brief <br />description of property damaged and dollar loss of the damage that occurred. (Use a separate sheet for additional <br />fires/damages) <br />Firework Type Cause of Fire/Damage Property Description Dollar Loss <br /> <br /> <br />