Free 11622.FH11 - Indiana

APPLICATION FOR FIREWORKS STAND RETAIL SALES PERMIT
State Form 11622 (R5 / 4-09) Approved by State Board of Accounts, 2009

DEPARTMENT OF HOMELAND SECURITY Division of Fire Safety 302 W. Washington Street, Room E241 Indianapolis, IN 46204 Telephone: (317) 232-2222

FOR OFFICE USE ONLY
Permit number

Fee ID number

DEADLINE FOR FILING RETAIL STAND IS JUNE 1ST.

Name of applicant

E-mail address

Address (number and street)

Telephone number

(
City State ZIP code

)

Address / Location of Temporary Stand (number and street)

City

State

ZIP code

County

Township

Date of issue (month, day, year)

Name of Fire Department of Jurisdiction

Address of Fire Department of Jurisdiction (number and street)

Merchant Certificate number (State Tax Identification number)

Signature of applicant

FEES FOR FIREWORKS - RETAIL STANDS 1 4 Retail Stands Retail Stands Retail Stands $ $ $ 276.00 552.00 966.00

5 - 10 11 - 20

21 - 50+ Retail Stands

$ 1,380.00