Required fields are marked with asterisks (*)

High Hazard (Display) Fireworks/Pyrotechnic

Event Application Form

Please allow 14 calendar days from date of applications for response

Name of Applicant:

Mailing Address:

Telephone No:

Email Address:

Supervisor's Certificate Number:

Class:

Company Name (if applicable):

Company's Mailing Address:

Company's Ph No:

Company's Email Address:

Sponsorship Organization (if aplicable):

Address of the Organization:

Event Location:

Event Date (s):

Place and Method of Pyrotechnic Storage on Site:

Documentation to Accompany Application:

Fire Safety Plan

Product List

Certificate of Liability Insurance-Minimum $5,000,000 Attached

Site Plan Attached

Event Descripton Attached

Property Owner Approval Attached

Copy of Display Supervisor I.D. Card Attached

Please upload your documents here:

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

File Uploads: A total upload for all the files included, shall not be over 15MB. Please resize or lower the quality of the file prior to upload.

Pursuant to s. 33 (c) of the Freedom of Information and the Protection of Privacy Act, the personal information collected on this form is for the purpose of an operating program or activity of the City of Medicine Hat. The City of Medicine Hat must collect personal information directly from the individual that the information is about unless another method of collection is authorized by the individual or by an enactment of Alberta or Canada. The personal information provided will be protected under Part 2 of the Freedom of Information and the Protection of Privacy Act and will be used for processing your application.

Questions regarding the collection and use of personal information can be directed to the FOIPP Head of Local Body at 403 529 8234

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

Signature of Applicant:

Clear

Date Signed:

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