Image (36)FIREWORKS RETAILER LICENSING APPLICATION
This form is used to apply fora single Fireworks Retailer License that will allow for the
operation of a single CFRS Facility within the State of Washington.
A single (1) Fireworks Retailers License costs forty dollars ($40.00). Include a single application for each license you
desire (one per each CFRS facility/stand) with a single check or money order covering them all made out to the
Washington State Patrol Fire Protection Bureau (WSP FPB). DO NOT SEND CASH.
All applications MUST BE RECEIVED BY NO LATER THAN May 1 for annual sales or November 1 for the New Year's
sales season. Post mark will suffice, but do not count on the mark alone — there are no exceptions allowed by law.
This is who the license will be issued to, normally a person. If the licensee is an entity, such as a non-profit organization,
then t7e member who signs as the applicant must be listed as an organizational member.
Business/Trade Name for Licensee (if different) Business UBI Number Business Phone Number
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Name and Title of Person Completing T is Form E-Mall Add ess
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Mailing Address (Complete Including Street, City, Slate, ZIP Code, and do not use building names)
In this section you will provide the specific information used to actually generate and track the license Issued.
County for CFRS Facility Physical Address (Complete Including Street, City, and ZIP Code)
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Person Operating CFRS Kacility Phone Number E-Mail Adress
List Below the Completed-N^ ame for Each Wholesaler That Will Supply Your CFRS Facillinty Fireworks:
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Signature of Partner or Corporate Officer
Printed Name and Title of Signatory Date of Signaturel
3000-420-029(R4/21) MUST RETURN