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2. Name
3. DOB
5. Address
7. City
8. State
9. Zip Code
11. Phone Number*
12. Email*
14. Permit Type

    1. Fireworks
    2. Explosives
15. Permit #
17. Reason for Replacement Request

    1. Lost
    2. Stolen

    1. Destroyed
    2. Other
18. If other, specify
20. Additional Comments (briefly explain):
22. This form must be filled out in its entirety before your request will be processed.
    If you have questions, please contact the Investigation Division at (785)296-8984.
24. By typing your name and date below, you attest that the information contained herein is true and accurate.
26. Applicant Name
27. Date
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field