Explosives permit application

Explosives permit application
Responsible party*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Date
Responsible party home address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Company / Corporation / Partnership / Entity name (If applicable)
Date of use from: Date* Date of use to: Date*
Address where explosives will be stored or used*

Street Address

Street Address Line 2

CityState

Zip Code
Explosives purchased from name*
Address of where explosives purchased from*

Street Address

Street Address Line 2

CityState

Zip Code
County where explosives will be used or stored*
Mining / Quarry operationsAgriculture / Natural resourcesRoad constructionBuilding construction / DemolitionOther
High explosivesLow explosivesBlasting agentsPowder onlyOther
The questions below refer to the responsible person listed on this application. If you answer yes to any of the following questions without the certificate* indicated, you are prohibited from obtaining a permit without further information.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Certificate of Treatment

If you answered “yes” to questions 3, 4, 5, or 6 on the front page of this application, you must provide proof from a medical doctor or psychiatrist licensed in Minnesota, or other satisfactory proof, that you no longer suffer from this disability, that you have not abused a controlled substance during the past two years, or that you have completed chemical dependency treatment.
Attached additional information here:*

Cancelof
Attach a copy of your ATF license and State or Federal ID such as a drivers license*

Cancelof
By signing below, you are certifying that you have read the information on both sides of this application and that the information provided is true and accurate.
Signature*

Clear
Title*
Statements Attested to by Signing this Application

By signing this application, I knowledge the following:
•I am the responsible party indicated on this application or, in the case of a corporation, agency,or association; I am authorized to sign this application on behalf of the corporation, agency, or association.
•Under penalties of perjury, I have examined this application and any supporting documents submitted, and to the best of my knowledge and belief, they are true, accurate, and complete.
•I am familiar with the applicable regulations, state laws and rules, and local ordinances relating to explosive and blasting agents for the location intended.
•Prior to the storage or use of explosives or blasting agents, the licensee will notify the appropriate local fire official and law enforcement agency.
•Minnesota Statutes, Chapter 299F.19 makes it unlawful to store explosive materials in amanner not in conformity with the rules and regulations of the Minnesota Department of Public Safety and the Federal Safe Explosives Act.

Data Practices Advisory

The Minnesota Data Practices Act requires that you be notified of the following information:
•As an applicant for an explosives user permit, you are being asked to provide private and/orconfidential data about yourself that will be used to check criminal histories, arrest records, and warrant information through the Minnesota Crime Information System and local police/sheriff files. This is being done to determine your eligibility to obtain an explosives user permit.
•You may refuse to provide this information. Should you refuse, this application will not be processed and no permit will be issued.
•The information that you provide will be used by the county sheriff or municipal police department to complete its investigation. This information may be conveyed to the Minnesota State Fire Marshal, the Minnesota Bureau of Criminal Apprehension, other law enforcement agencies, or treatment facilities identified through this application or investigation.
Please verify that you are human*
Should be Empty:

Explosives permit application

By signing below, you are certifying that you have read the information on both sides of this application and that the information provided is true and accurate.