Texas Department of Insurance
State Fire Marshal’s Office Mail Code 112-FM
333 Guadalupe • P. O. Box 149221, Austin, Texas 78714-9221
512-305-7900 • 512-305-7922 fax • www.tdi.state.tx.us
	
	PYROTECHNIC, SPECIAL EFFECTS AND FLAME EFFECTS OPERATOR’S LICENSE APPLICATION	
This application must be accompanied by all documents and information required by Chapter 2154 of the Texas Occupations Code and the Fireworks Rules, AND THE ORIGINAL SCORE REPORT RECEIVED FROM THOMSON PROMETRIC SHOWING A PASSING SCORE FOR THE REQUIRED EXAMS.
Complete answers must be given to all items.  Please print or type.
An operator's license shall not be issued to any person who is under 21 years of age.
Any fraudulent representation on this application may be cause for denial, suspension, or revocation of a license.
All fees are non-refundable, except for overpayments resulting from mistakes of law or fact.
LICENSE	
CHECK ONE	TYPE OF LICENSE	LICENSE FEE	CODE	DO NOT SUBMIT THIS APPLICATION UNTIL ALL TEST REQUIREMENTS HAVE BEEN MET
	
	Pyrotechnic Operator	$45	570-05		
	Pyrotechnic Special Effects Operator	$45	570-11		
	Flame Effects Operator	$45	128	
APPLICANT	
LAST NAME	FIRST NAME AND MIDDLE NAME	HOME AREA CODE AND TELEPHONE	

			
HOME ADDRESS	CITY	STATE	ZIP CODE	

				
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)	CITY	STATE	 ZIP CODE	

				
E-MAIL ADDRESS (optional)	WEB SITE ADDRESS (optional)	

COUNTY OF RESIDENCE	DRIVER'S LICENSE NUMBER AND STATE	SOCIAL SECURITY NUMBER	DATE OF BIRTH	

				
WEIGHT	HEIGHT	SEX	COLOR OF HAIR	COLOR OF EYES	

					
APPLICANT'S EMPLOYER	
NAME OF FIRM	AREA CODE AND TELEPHONE	

		
ADDRESS OF FIRM	CITY	STATE	ZIP CODE	

				
RESIDENCE HISTORY	
Have you resided in any other state besides Texas, or foreign country, in the last 10 years?     YES     NO   If yes, list other states and/or countries.	
	
Please attach your criminal history report from any state other than Texas where you lived for a total of six months or more.  The report should be a current statewide report showing that a search for misdemeanor and felony convictions was made and giving the results of that search.  Our office can provide information about specific state requirements and agencies to contact.  If you were on active duty with the United States military when you lived outside of Texas, it may be possible for you to submit a copy of your military discharge, DD Form 214, MEMBER-4 copy showing honorable service, instead of the state reports.	
QUESTIONS	
1	Do you hold a current license issued by the Texas State Fire Marshal?
If yes, print license number(s) here.	YES
	NO
	
2	Have you ever held a license issued by the Texas State Fire Marshal that is not shown in question 1 above?
	YES
	NO

QUESTIONS (cont)	
3	Have you ever had a permit or license denied, suspended, or revoked?
If yes, give details on a separate sheet and attach it to this application.	YES
	NO
	
4	Have you ever been convicted of a misdemeanor or a felony (including any pending adjudication)?
If yes, give details on a separate sheet and attach it to this application.	YES
	NO
	
5	Do you store fireworks in the state of Texas?  If yes, please complete the section below.	YES
	NO
	
LOCATIONS IN TEXAS WHERE YOU STORE FIREWORKS (List all locations where fireworks 1.3G & 1.4G are stored)	
INDICATE CLASSIFICATION CODE 1.4G OR 1.3G	LOCATION
(If no street address, please describe exact location)	ESTIMATED MAX. WEIGHT
DURING THE YEAR	
	Street Address	City, State	Gross Weight	* Net Weight	

					
	* Net weight is the weight of all pyrotechnic and explosive compositions and fuse only.	
PUBLIC FIREWORKS DISPLAY EXPERIENCE	(to be completed by pyrotechnic operator applicants – not special effects or flame effects)	
List five permitted or licensed public displays using Fireworks 1.3G that you assisted in conducting in the State of Texas under the direct supervision of a pyrotechnic operator licensed in Texas.  Written verification from the pyrotechnic operator is required.	
LOCATION	DATE	PYROTECHNIC OPERATOR'S NAME	PYROTECHNIC OPERATOR'S LICENSE NO.	

				
LOCATION	DATE	PYROTECHNIC OPERATOR'S NAME	PYROTECHNIC OPERATOR'S LICENSE NO.	

				
LOCATION	DATE	PYROTECHNIC OPERATOR'S NAME	PYROTECHNIC OPERATOR'S LICENSE NO.	

				
LOCATION	DATE	PYROTECHNIC OPERATOR'S NAME	PYROTECHNIC OPERATOR'S LICENSE NO.	

				
LOCATION	DATE	PYROTECHNIC OPERATOR'S NAME	PYROTECHNIC OPERATOR'S LICENSE NO.	

				
SIGNATURES	
In applying for a pyrotechnic operator's license, a special effects operator’s license, or a flame effects operator’s license, I certify that I will comply with Chapter 2154 of the Texas Occupations Code, and the Fireworks Rules.
I know of no reason why I should be denied a license.
By my signature, I verify that the information, included or provided on this application and any attachment, is complete and 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.	
SIGNATURE OF INDIVIDUAL APPLICANT	DATE	

Check or money order should be made payable to the TEXAS DEPARTMENT OF INSURANCE.
Mail this completed application along with the appropriate fee and any additional documents to:

Mailing 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, Texas  78714-9221	Telephone No.	512-305-7930
		Fax No.	512-305-7922
		Web Site Address:	www.tdi.state.tx.us

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 & Compliance Division at (512) 475-1757 or visit the Corrections Procedure section of TDI’s web page at www.tdi.state.tx.us.