Missouri Pyrotechnics Association
MOPYRO
Application must be legible, completed fully, signed and dated. PLEASE PRINT
Return fully completed application and payment to:
Kent Zimmerman Check One:
9526
Brenda Ave.
New Application
St.
Louis MO 63123
Renewal Application
Please Print Clearly
Name____________________________________________________________________
Address__________________________________________________________________
City __________________________________State ________________Zip____________
Home Phone (___) _____________________Cell Phone (___) ______________________
E-Mail___________________________________________________________________
Missouri Licensed Shooter? (Yes)____ (No) ____ PGI Shooter Certified? (Yes)____ (No) ____
(For Family Membership)
Children (Under 18) ___________________________________________________________________
(Check One)
$20 One Week $50 Single
$75 Family $100
Sponsor
One Week: Available only to members of other Fireworks Clubs, or with MoPyro sponsor. (No vote, no newsletter)
Single: Basic membership level with all rights and privileges. (1 vote, 1 newsletter)
Family: Two adults and children under 18. List children’s names above. (2 votes, 1 newsletter)
Sponsor: (1 vote, 1 newsletter) Extra employees/family members $25 each, no vote or newsletter. All must sign Disclaimer.
Disclaimer: Please Read - Signature(s) Required
The undersigned registrants agree to indemnify and hold harmless the Missouri Pyrotechnics Association and each of its officers, directors, members and successors from and against all claims for damage, injuries, or consequences arising out of any direct and/or indirect or collateral participation in activities associated with Missouri Pyrotechnics Association, including meetings, displays, demonstrations, seminar attendance, hands on training, education materials, (including all processes and products covered in such meetings, displays, demonstrations, seminar attendance, hands on training, education materials) and other activities by the undersigned persons. The undersigned further agrees to abide by all safety rules and regulations, follow directions of the safety team, and to supervise their children and children in their charge at all times. Violations of the above may result in immediate suspension of MoPyro activities and/or membership.
The Undersigned also certify that they are not a member of the class of “prohibited Persons” as specified in the Bureau of Alcohol, Tobacco, Firearms and Explosives, “Explosives Laws and Regulations”, publication ATF P 5400.7, Subpart C, section 555.26 (“The Orange Book”). “Prohibited Persons” may be members, but may handle ONLY 1.4g (“Class C”) material.
New registrants will be sent a copy of the MoPyro By-Laws and Safety Guidelines, and will agree to follow and be bound by those By-Laws and Safety Guidelines.
Signature________________________________________________ Date_____________
Spouse Signature__________________________________________ Date_____________
(Make Checks Payable To: Missouri Pyrotechnics Association)