Name:

Address:

Phone:

Date of Birth

PGI Member Status:

(It is not necessary to be a PGI member to be certified)

Course Passed (year):

Fireworks Experience (5 Shows/Events):  One display must be done as lead operator under supervision.  Supply documentation as best you can, such as: date/location and signature and/or letterhead of company with whom you worked).

1.

2.

3.

4.

5.

Note which display was done with you as lead operator, and provide the supervisor's name and contact information.

Signature _________________________________

When complete, mail the form and $5.00 to:

Gene Zdrazil

6090 River Jct. Rd SE

Lone Tree, IA  52755

Note:  Please describe the type of display (manual, electrical, single or multiple site, choreographed to music or not, etc.)  Describe the exact role you played and the duties you performed.