PERMIT TO PURCHASE AND USE CONSUMER FIREWORKS

This permit is issued to ______________________________, who is hereby granted

permission to purchase consumer fireworks for the purpose of personal display. The
fireworks are to be used on the day(s) of _________________________________ at the
following location: _______________________________________________________.
Permission is also granted to possess the 1.4G consumer fireworks and transport them to
the location shown above.
This permit may not be issued to anyone younger than 18 years of age, and must be
signed by a local government representative such as police, fire, supervisor, councilman
or other representative.

______________________________________
Signature of Representative Issuing Permit

______________________________________
Printed Name

______________________________________
Title

Date: _________________________________

Release of Liability
Important: The merchandise is sold by Keystone Fireworks upon the condition that the seller, governing official,
agent of issuing municipality and the municipality itself shall not be liable for any arrest, accident or injury occasioned
during the transportation, handling, storage, sale or use of the merchandise. The undersigned is aware of the dangers of
fireworks and is willing to assume full responsibility for the use, handling and transportation of these products. The
undersigned specifically agrees that he / she will not bring any action against the seller, governing official or
municipality for any claims that may arise from the use, storage, transportation or resale of sellers products, including
injuries to buyer or any third parties. This release is executed freely and voluntarily by the undersigned for the purpose
of protecting the seller and the municipality from potential future liability. The undersigned understands and
acknowledges the significance and consequences of such specific intention to release any and all future claims against
the seller, the municipality and its agents.

______________________________________
Signature of Buyer