Special Effect Pyrotechnics Safety and Legal Awareness Course Registration

Please PRINT clearly. Applicant fills out Sections A and B; do not fill out Section C

A. APPLICANT INFORMATION

Family Name ________________________________________

Given Name ________________________________________

Date of Birth (yyyy/mm/dd) ____________

Mailing Address ________________________________________

City ______________

Province/Territory __________________________

Postal Code __________

Telephone _______________

Fax ________________________________________

E-Mail ________________________________________

Organization (if related to pyrotechnics) ____________________

Signature of Applicant ________________________________________

□ Fireworks Operator Certificate: Pyrotechnician – may use basic pyrotechnics if unsupervised, however, use of all other authorized pyrotechnics must be supervised.
□ Other (i.e., already certified)
□ Authority Having Jurisdiction - Members of the public services who are responsible for the authorization and support of pyrotechnics events, such as fire prevention officers, firefighters, and other members of agencies responsible for the carrying out of pyrotechnics events. A letter confirming the status of AHJ must be submitted with the registration form.

Course Location City: ____________________________

Province/Territory: ____________________________

Date of Course (yyyy/mm/dd) ____________________________

Registration Requirements for the Special Effect Pyrotechnics Safety and Legal Awareness Course:

Fee is $150.00. Note: Fee is waived for those attending as Authority Having Jurisdiction only;
To register for Special Effect Pyrotechnics Safety and Legal Awareness Course, mail registration form, payment and one current photo to the ERD region where the course is being held. Please note:
Form F17-01 must be completed and signed;
Accepted methods of payment are certified cheque or money order only payable to Receiver General for Canada; and
Digital photos are now accepted. Email the photo to the email address in your region. Photos must be in JPEG format with your last name as the file name (i.e., Smith.jpg). Ensure your name, course location and date is in the subject line.

Canada: (excluding Quebec)
580 Booth Street, Ottawa (ON) K1A 0E4
Tel. (613) 948-5200, Fax. (613) 948-5195, Email: canmet-erd@nrcan.gc.ca

Quebec:
P.O. Box 100, 2050 Girouard West, Saint-Hyacinthe (QC) J2S 7B2
Tel. (450) 773-3431, Fax. (450) 773-6226, Email: EasternRegion@nrcan.gc.ca

FINANCE

Cheque or Money Order No._________ Fee Paid: $ _______ Reference no._________

PYRO ID:

Certificate No.: ____________Type: ______________ Expiry Date: _____________

Approved by: ____________________ Date: _______________________