Commonwealth of Pennsylvania

Permit To Purchase Fireworks

For Personal Display

Or Public Entertainment Purposes


City/Town/Borough:____________________________ County:_______________________________

This permit is issued to: _______________________________________________________________

Address: __________________________________________________________________________

giving the above named individual the right to purchase 1.4G consumer fireworks from Keystone Fireworks and to display the 1.4G consumer fireworks on the __________ day of ______________ 20_________, at ______________ o'clock ____.M. at the following location:



in the City/Town/Borough: _______________________ County: _______________________________

and permission is also granted to possess the 1.4G consumer fireworks and transport them to the above said

shooting site location.

By: _________________________________________ Date: _________________________________



Printed Name of Officer Issuing Permit


Title & Jurisdiction of Officer Issuing Permit

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 seller’s 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