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Rev: May-26 TOWN OF BOSTON Section 1: General Information Name of Group Sponsoring the Show: _____________________________________________________________ Address: ______________________________________________________________________________________________ Phone: ______________________________ Contact Person’s Name: ____________________________________ Display Company Name: ____________________________________________________________________________ Address: ______________________________________________________________________________________________ Phone: ______________________________ Contact Person’s Name: ____________________________________ NYS Depart. of Labor Explosives License # _______________________________ Expires: _____________ Section 2: Display Information (A) Name of Certified Pyrotechnician(s) who will oversee the display: Operator Name / Age Certificate # / Expiration Phone Number in Charge (place X) Date 2 *Please use a separate sheet, if necessary. Page Town of Boston 8500 Boston State Road • Boston, New York 14025 Phone (716) 941-6113 • Fax (716) 941-6116 www.bostonNY.gov