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2. Application Type
   -- Select One --NewRenewal
6. I. Legal Name
   For background purposes, use full legal name. This name will also be printed on applicant's permit.
8. Last
9. First
10. MI
14. II. Current Hobbyist Permit (if renewal) #
18. III. Current Display Operator's Permit #
20. Attach copy of permit
24. IV. Physical & Mailing Address
26. Physical Address
28. City
29. County
30. State
31. Zip Code
33. Mailing Address
35. City
36. County
37. State
38. Zip Code
42. V. Personal Information
44. Date of Birth
45. Current Age (in years)
46. Gender
    -- Select One --MaleFemale
48. Last 4 Digits of Social Security #
49. Driver's License
50. State
52. U.S. Citizen?
    -- Select One --YesNo
53. If not a U.S. citizen, please provide Alien Registration #
55. Have you been convicted of a felony?
    -- Select One --YesNo
59. VI. Contact Information
61. Home Phone Number
62. Mobile Phone Number *
64. Email*
68. VII. Location of Manufacturing Operations
72. VIII. Types of Fireworks Manufactured
76. IX. Storage
78. Applicant will store display fireworks in Kansas?
    -- Select One --YesNo
79. If yes, provide permit #
81. 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.
85. 10. 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.
87. By typing your name and date below, you attest that the information contained herein is true and accurate.
89. Applicant Name
90. Date
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field