CONSUMER FIREWORKS AUTHORISED RECEIPT
DANGEROUS SUBSTANCES (EXPLOSIVES) REGULATION 2004		
You must keep this receipt This receipt authorises the named consumer to use the fireworks shown on this receipt
between 5pm-10pm Saturday, Sunday, Monday of the Queen’s Birthday long weekend in the year of issue at the location shown.

Consumer Details                                                                                                   CONSUMER MUST BE 18 YEARS OR OLDER	
 Name____________________________________________ DOB_____/_____/_____	

Residential address (must be an ACT address)	
 No__________Street_________________________Suburb_________________________ACT______	

 Are the fireworks to be used at the above address?                    YES             NO  	
	
If you ticked NO, indicate where in the ACT the fireworks are to be used

This must be an A C T address	
No__________Street_________________________Suburb____________________________ACT______	

WHAT PHOTO ID WAS SHOWN BEFORE PURCHASING THESE FIREWORKS?	
    DRIVERS LICENCE                  PROOF OF AGE CARD                  PASSPORT
  OTHER___________________________________ NUMBER ON ID________________________	

If the primary ID does not show the above ACT residential address you need supporting evidence that the consumer lives in the ACT.	
eg rates notice/bank statement/rent receipt/Doctors referral/invoice etc;	
WHAT IS THE SUPPORTING EVIDENCE? _____________________________________________________	

 DATE _____/6/200_____	 Consumer SIGNATURE__________________________________ 

LICENSEE USE ONLY	

DETAILS OF FIREWORKS SOLD TO CONSUMER                                                LICENSEE DETAILS	

BAG TYPE	
# SOLD	
BAG TYPE	
# SOLD	
	
Licence number	

BAG 1	
	
BAG 6	

Name	

BAG 2	
	
BAG 7	

	

BAG 3	
	
BAG 8	

Location of Premises	

BAG 4	
	
BAG 9	

	

BAG 5	
	
BAG 10	

	

Sparklers	

	

Important information for buyers
•	Fireworks must not be used in a way that endangers or injures any person or animal, or damages any property.
•	Fireworks must not be used on unleased ACT land without prior approval.
•	Fireworks must not be used during a total fire ban. It is your responsibility to check fire ban status.
•	All fireworks must be transported, stored and used as per the instructions supplied at purchase.
•	It is an offence to possess or use fireworks without an authority: max. penalty $75,000 and/or 3 years imprisonment.

Buyer (consumer)	Seller (licensee)	ACT Office of Fair Trading	
White copy	Yellow copy	Green (book) copy