Required fields are marked with asterisks (*)

Fireworks Display Application

Please read and review the attached Fireworks By-Law and submit the following completed items to Firecheif@westelgin.net

All applications must be submitted at least 14 days prior to the display.

Event Information

Event Date

Alternate date

Start Time of display

Event Location (Address or general description)

Contact Information

Name/Organization

Address

Phone Number

Email Address

Fireworks Vendor Information

Vendor Name

Address

Telephone Number

Email Address

Supervisor Name

Supervisor Card Number

Supervisor Level

Supervisor Telephone Number

Copy of Valid Fireworks Supervisor Card (please attach)

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Property Owner Information

Same information as Applicant

Yes

Insurance Information

Insurance Company Name

Insurance Policy Number

Dates of Coverage

Please provide a copy of the liability insurance in the amount of $5 Million. Note if the display is to take place on Municipal property the Municipality of West Elgin must be named as additional insured

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Safety Plan Information

Types of Fireworks to be discharged

Discharge Method

Electrical

Hand-fired

Combination

Other

Method of disposal of unused fireworks

Security Barriers and Measures in place

Emergency Procedures

Site Plan

Please attach a drawing with dimensions of the proposed site and include the following:

Location of the proposed fireworks display
Proposed access of fire and emergency vehicles
Free zone, have a clear distance between the point of launch and occupied area

Please upload your Site Plan Drawing

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Applicant's Signature

Clear

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Fireworks Display Application

Event Information

Contact Information

Fireworks Vendor Information

Property Owner Information

Insurance Information

Safety Plan Information

Site Plan