HomeMy WebLinkAboutImage` FIRE PROTECTION BUREAU UN.
EDUCATION, ENFORCEMENT, AND ANALYTICS SECTION
PO Box 42642
''y*•�•°''° Olympia WA 98504-2642
(360) 596-3946 FAX: (360) 596-3934
Fireworks@wsp.wa.gov
FIREWORKS RETAILER LICENSING APPLICATION
This form is used to apply for a 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 the member who signs as the applicant must be listed as an organizational member.
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Fireworks Retailer Licen ee The name of the person or organization being licensed.
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Business/Trade Name for Licensee (if different) Business UBI Number Business Phone Number
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Name and Title of Per on Completing This Form E-Mail Address
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Mailing Address (Complete Including Street, City, State, ZIP Code, and do not use building names)
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Street Address (Complete Including Street, City, State,'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.
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County for CIF S Facility Physical Address (Complete Including Street, City, and ZIP Code)
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Person Operating CF S Fadlity Phone Number E-Mail Address
List Below the Complete Name for Each Wholesaler That Will Supply -Your CFRS Facility Fireworks:
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I, the undersigned, hereby declare under penalties of perjury and/or revocation that I am the applicant or authorized
representative of the applicant and attest that all information provided herein is complete, correct, and true to the best of
my ability. I have thoroughly read the instructions and provisions of this application, understand them, and as a Fireworks
Retailer Licensee will abide by and obey the laws and rules governing this license and the provisions of the local
jurisdiction who issues my CFRS Facility's operational permit.
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Signature of Applicant/Authonz d Representative Printed Name and Title of Signatory Date of Signature
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Signature of Partner or Corporate Officer Printed Name and Title of Signatory Date of Signature
3000-42o-02e(R4rz1) MUST RETURN