Form Atf F 5400.21 - Application For Permit User Limited Display Fireworks

OMB No. 1512-0399 (10/31/99)

DEPARTMENT OF THE TREASURY

BUREAU OF ALCOHOL, TOBACCO AND FIREARMS

APPLICATION FOR PERMIT USER LIMITED DISPLAY FIREWORKS

UNDER 18 US.C. CHAPTER 40, EXPLOSIVES

NOTE: Complete in duplicate. Use typewriter or print with ball point pen. Application fee of $75 should be paid by check or money order

made payable to: BUREAU OF ALCOHOL, TOBACCO AND FIREARMS.

read instructions on the back of this form.)

(Please

1. NAME (If partnership, include name of each partner)

3. EMPLOYER IDENTIFICATION NUMBER (Voluntary see back of

2. TRADE NAME, IF ANY

this form)

5. ADDRESS (RFD or street no., city, State, and ZIP Code)

4. NAME OF COUNTY

from nearest PO. or city limits)

BUSINESS:

RESIDENCE:

8. FIREWORKS WILL BE PURCHASED FROM:

NAME:

ADDRESS:

TELEPHONE NO.:

FEDERAL EXPLOSIVE LICENSE NUMBER:

STORAGE FACILITY

INFORMATION

10. TYPE, LOCATION AND DESCRIPTION OF STORAGE FACILITY, (Attach magazine description worksheet for each magazine) IF NO STORAGE. LIST PROVISIONS FOR

STORAGE SHOULD FIREWORKS BE RECEIVED EARLIER OR LATER THAN EXPECTED OR NOT USED WITHIN 24 HOURS AFTER RECEIPT.

11. RESPONSIBLE PERSON(S) (See back of this form) (If additional space is needed, use a separate sheet)

DATE

FULL NAME

HOME

P L A C E

SEX

AND POSITION

OF BIRTH

ADDRESS

OF BIRTH

_

I

I

|

NO

YES

GIVE FULL DETAILS ON SEPARATE SHEET FOR ALL “YES’’ANSWERS IN ITEMS 12 & 13

12.

a. Been charged by information or under indictment in any court for a crime punishable by imprisonment for

HAS APPLICANT OR

ANY PERSON NAMED

a term exceeding one year?

IN ITEM 11 ABOVE:

b. Been a fugitive from justice?

c. Under 21 years of age?

d. Been an unlawful user of or addicted to marijuana or any depressant, stimulant or narcotic drug?

13. HAS APPLICANT OR a. Been convicted in any court of a crime punishable by imprisonment for a term exceeding one yeaf ? (NOTE: The actual sen-

tence given by the judge does not matter - A “YES” answer i

necessary if the judge could have given a sentence of more than

ANY PERSON

S

NAMED IN ITEM 11

one year. Also, a “YES” answer is required if a conviction has been discharged, set aside, or dismissed pursuant to an expunge-

ABOVE:

b. Been adjudicated as a mental defective or been committed to any mental institution?

14. CERTIFICATION Under the penalties of perjury Imposed by 18 U.S.C. 844, I declare that I have examined this application and documents submitted in support thereof, and to the

best of my knowledge and belief, they are true, correct, and complete. I also certify that I am familiar with all published State laws and local ordinances relating to display fireworks

for the location in which I intend to do business and that if I reuse this permit beyond the one transaction which it authorizes, I subject myself to criminal penalties

DATE

APPLICANT’S SIGNATURE

TITLE

ATF USE ONLY

15. APPLICATION IS

TERMINATED

DISAPPROVED

15A. REASON FOR TERMINATION OR DISAPPROVAL OF THIS APPLICATION

ATF F 5400.21 (11-98) PREVIOUS EDITIONS ARE OBSOLETE