
QUESTIONS
Size and estimated number of 1.3G fireworks to be discharged:
Other items (1.4G fireworks, flame effects, set pieces, etc.)
Manner and address of storage of fireworks prior to and during the display
Manufacturer or distributor licensed in Texas who is to supply the fireworks:
Name License number
SIGNATURES
In applying for a fireworks permit, I certify that I am familiar with and will comply with Chapter 2154 of the Texas Occupations Code and
the Fireworks Rules.
I hereby authorize the state fire marshal or any of his duly authorized deputies, upon notice, to enter, examine, and inspect any
premises, building, room, or establishment used in connection with the permit for which I am applying to determine compliance with the
provisions of Chapter 2154 and the Fireworks Rules.
By my signature, I verify that the information on this application and its attachments are true.
I understand that knowingly providing a false answer to any question or submitting false information or documents with this application
may be tampering with a governmental record which is punishable under the Texas Penal Code Chapter 37, §37.10.
Printed name Title
Signature Date
Printed name Title
Signature Date
APPLICATIONS MUST BE SIGNED BY AN INDIVIDUAL APPLICANT, BY AN OFFICER OF A CORPORATION, BY THE SOLE
PROPRIETOR, BY EACH PARTNER OF A GENERAL PARTNERSHIP, BY THE GENERAL PARTNER OF A LIMITED LIABILITY
PARTNERSHIP OR BY AN OFFICER OR MEMBER OF A LIMITED LIABILITY COMPANY.
APPLICATIONS SUBMITTED BY A GOVERNMENTAL ENTITY MUST BE SIGNED BY THE APPROPRIATE OFFICER. FOR
EXAMPLE, A CITY’S APPLICATION SHOULD BE SIGNED BY THE MAYOR, CITY MANAGER, CITY ADMINISTRATOR, CITY
SECRETARY, ETC.
Check or money order should be made payable to the TEXAS DEPARTMENT OF INSURANCE.
Mail this completed application along with the appropriate fee and additional documents to:
Mail Address: State Fire Marshal’s Office Physical Address: State Fire Marshal’s Office
Mail Code 9999 333 Guadalupe
P. O. Box 149221 Austin, TX 78701
Austin, TX 78714-9221 Fax No. 512-305-7922
512-305-7930 Web Site Address:
www.tdi.texas.gov/fire
NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES
With few exceptions, you are entitled to be informed about the information that the Texas Department of Insurance (TDI) collects about you. Under sections
552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information.
However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government Code, you are
entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining
information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI’s Legal and Regulatory
Affairs Division at 512-475-1757 or visit the Corrections Procedure section of TDI’s web page at www.tdi.texas.gov.
SF044 Rev. 12/13 Page 2 of 5