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2. Application Type
   -- Select One --NewRenewal
6. I. Distributor Name
10. II. Applicant's Current Permit #(if renewal)
14. III. Permit Class
    -- Select One --Display Fireworks (1.3)Consumer Fireworks (1.4)Articles PyrotechnicUnlimited
18. IV. Physical & Mailing Address
20. Physical Address
22. City
23. County
24. State
25. Zip Code
27. Mailing Address
29. City
30. County
31. State
32. Zip Code
36. V. Contact Information
38. Home/Office Number
39. Mobile Number*
41. Email Address*
45. VI. Storage
47. Applicant will store display fireworks in Kansas?
    -- Select One --YesNo
48. If yes, provide permit #
50. According to K.S.A. 31-504, the owner of any display fireworks storage facility shall obtain a storage site permit from the Kansas State Fire Marshal for permanent storage. Permits are not required for day boxes used at display sites or if there is a contingency plan with another permitted operator/distributor. It is unlawful to store display fireworks (1.3) if not permitted.
56. VII. Responsible Parties
    Individuals who can direct management/policies of applicant pertaining to explosive materials
58. A. Last Name
59. First Name
60. MI
61. Date of Birth
63. Last 4 Digits of Social Security #
64. Driver's License
65. State
67. Address
69. City
70. State
71. Zip Code
73. U.S. Citizen?
    -- Select One --YesNo
74. If not a U.S. Citizen, please provide Alien Registration #
76. Have you been convicted of a felony?
    -- Select One --YesNo
78. B. Last Name
79. First Name
80. MI
81. Date of Birth
83. Last 4 Digits of Social Security #
84. Driver's License
85. State
87. Address
89. City
90. State
91. Zip Code
93. U.S. Citizen?
    -- Select One --YesNo
94. If not a U.s. Citizen, please provide Alien Registration #
96. Have you been convicted of a felony?
    -- Select One --YesNo
98. C. Last Name
99. First Name
100. MI
101. Date of Birth
103. Last 4 Digits of Social Security #
104. Driver's License
105. State
107. Address
109. City
110. State
111. Zip Code
113. U.S. Citizen?
     -- Select One --YesNo
114. If not a U.S. Citizen, please provide Alien Registration #
116. Have you been convicted of a felony?
     -- Select One --YesNo
120. VIII. Applicant's Signature
     Under the penalties imposed by K.S.A. 21-3805, I declare that I have examined this application and any documents submitted in support thereof, and to the best of my knowledge and belief, they are true, correct and complete. I also certify that I am familiar with all published state laws and local ordinances relating to firework materials for the location(s) in which I intend to do business.
122. By typing your name and date below, you attest that the information contained herein is true and accurate.
124. Applicant Name
125. Date
Leave This Blank:


127. 1. Receive an email copy of this form.
128. Email address

     This field is not part of the form submission.

129. Submit

* indicates a required field