THE UNDERSIGNED, TOWN CHAIRMAN, TOWN SUPERVISOR, TOWN CLERK, OR OTHER OFFICIAL SO DESIGNATED:

 TOWN OF: CLOVERLAND COUNTY OF: VILAS WISCONSIN HEREBY AUTHORIZES THE FOLLOWING NAMED PERSON OR ORGANIZATIONS 

NAME________________________________________________________________

ADDRESS:____________________________________________________________ 

____________________________________________________________________ 

TO PURCHASE OR POSSESS CLASS C FIREWORKS ON OR AFTER THE ISSUE DATE OF THIS PERMIT 

DATE:________________________________________________________________

ADDRESS AND DATE OF USE____________________________________________

THIS PERMIT FOR THE PURCHASE AND USE OF ANY AMOUNT OF CLASS C FIREWORKS ONLY.

 WISCONSIN STATE LAW: A COPY OF THIS PERMIT MUST BE GIVEN TO A MUNICIPAL FIRE OR LAW ENFORCEMENT OFFICIAL TWO DAYS BEFORE USE. 

This permit is Issued upon the condition that the Town of Cloverland shall not be liable in any civil action for any accident or Injury occasioned during the transportation, handling, storage, or use of said fireworks. 

I AGREE TO THIS CONDITION: 

SIGNATURE OF PERMIT HOLDER ________________________________________ 

SIGNATURE OF DESIGNATED OFFICIAL__________________________________ 

THIS PERMIT IS FOR THE ADDRESS AND DATE SHOWN ABOVE ONLY.

TO USE FIREWORKS AT ANY OTHER TIME OR PLACE YOU MUST SECURE ANOTHER PERMIT.