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Fireworks Sale Permit Application

2. Organization/Business*

3. Kansas Sales Tax Number*

5. Responsible Party*

6. Application Date*
   Application Date

7. Fee
   $5000

   $5000

9. Street Address*

11. City*

12. State*

13. Zip Code*

17. Display

18. Date of Event
    Date of Event

20. Street Address

24. Retail Sale

25. Dates Open
    Dates Open Start Date

    —

    Dates Open End Date

27. Street Address

29. Send payment to City of Clearwater PO Box 453 Clearwater, KS 67026

    Send payment to City of Clearwater PO Box 453 Clearwater, KS 67026

33. For Office Use Only

34. Permit Number

36. City Clerk

37. Fire Chief

39. Date
    Date

40. Date
    Date

Leave This Blank:


41. Print Only

* indicates a required field