Note*: [PLEASE DO NOT STAPLE]{.underline}*

**1. Item Name:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **This is
a series application (Y/N): \_\_\_\_\_\_\_\_\_**

**2. Applicant:**

> [Name/Title]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Company Name]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Address]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Phone]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Fax]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Email]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> **Note:** A foreign applicant must provide a designated U.S. agent of
> service (name of contact person, email address and phone number
> required).
>
> [U.S. responsible party]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Name/Affiliation]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Address]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Phone]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Fax]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Email]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3. DOT Class:**

>  Fireworks UN 0336, 1.4G  Fireworks UN 0335, 1.3G
>
>  Fireworks UN 0333, 1.1G  Article Pyrotechnic UN 0431, 1.4G
>
>  Other: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**4. Manufacturer:**

> [Company Name]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Address]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Phone]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Fax]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> [Email]{.underline}:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**5. Category of Device:** (*under APA 87-1*):

>  Cylindrical Fountain  Cone Fountain
>
>  Rocket  Mine/Shell
>
>  Roman Candle  Wheel
>
>  Reloadable Shell Kit  Other:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
>  Aerial Shell (non-salute)
>
>  Aerial Shell (salute)  Other:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

6.  **Diagram of the Device: Attach as a separate file**

```{=html}
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```
7.  **Chemical Composition: See attached chemical composition sheet**

8.  **Description of Device:**

> Number of tubes: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Tube separation (over 200 gram device):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Diameter of device (or range of diameters for a series):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Maximum powder weight per tube: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> For 1.4G mine/shell: Max. propellant/tube:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Maximum effect/tube (including burst):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Total powder weight in device: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Tubes are fused in sequence (*if UN0336 multiple-tube item*) (*yes /
> no*) \_\_\_\_\_\_
>
> Does item have a report? (yes/no) \_\_\_\_\_\_\_
>
> Number of reports per tube: \_\_\_\_\_\_\_\_\_\_\_\_ Number of
> tubes:\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> If yes, max. weight per individual report: \_\_\_\_\_\_\_ mg
>
> Total weight of report powder in item: \_\_\_\_\_\_\_ grams
>
> Effect produced (e.g., shoots red star in air):
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

9.  **For Reloadable Shell Kits**:

> (**Note**: Reloadable shell kits are limited to 400 grams of
> pyrotechnic composition and must be packaged in a ratio not to exceed
> 12 shells to 1 tube)

Maximum number of shells per kit: \_\_\_\_\_\_\_\_\_

Maximum weight of pyrotechnic composition per shell: \_\_\_\_\_\_ grams

Maximum total weight of pyrotechnic composition per kit: \_\_\_\_\_\_\_
grams

Each kit contains at least one launching tube: (*yes/no*)
\_\_\_\_\_\_\_\_\_\_

**10. Thermal stability test results:**

> A thermal stability test of this device was performed on
>
> [*(date*) (*name of tester*) (*job title*) (*company*)]{.underline}
>
> The test was performed on:  finished item  component chemical
> mixtures, as present together in the device. The device did not
> ignite, explode, or undergo any significant decomposition during
> heating at 75º C (167º F) for 48 hours.

**11.** **Certification**:

> This is to certify that the device for which approval is requested
> conforms to APA Standard 87-1 and that the descriptions and technical
> information contained in this application are complete and accurate.
>
> [(date) (Signature of applicant named above) (typed name of applicant,
> in English)]{.underline}

**Chemical Composition List for (***Item name***):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Total weight of pyrotechnic composition in Item:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Effect and total weight for each composition (***e.g., red star -- 21
g; propellant -- 18 g***):**

1\. \_\_\_\_\_\_\_,\_\_\_\_\_g 3. \_\_\_\_\_\_\_,\_\_\_\_\_\_g 5.
\_\_\_\_\_\_\_\_,\_\_\_\_\_\_g

2\. \_\_\_\_\_\_\_,\_\_\_\_\_g 4. \_\_\_\_\_\_\_,\_\_\_\_\_\_g 6.
\_\_\_\_\_\_\_\_,\_\_\_\_\_\_g

Weight %

  -------------------- -------------- ------- ------- ------- ------- ------- -------
  **Chemicals**[^1]                   1       2       3       4       5       6

  Potassium Nitrate    KNO~3~                                                 

  Potassium            KClO~4~                                                
  Perchlorate                                                                 

  Ammonium Perchlorate NH~4~ClO~4~                                            

  Barium Nitrate       Ba(NO~3~)~2~                                           

  Strontium Nitrate    Sr(NO~3~)~2~                                           

  Sulfur                                                                      

  Charcoal                                                                    

  Aluminum\*\*\*\*                                                            

  Magnallum \*\*\*\*   Mg/Al alloy                                            

  Dextrine                                                                    

                                                                              

                                                                              

                                                                              

                                                                              

  **RESTRICTED**       **CHEMICAL**                                           

  Potassium Chlorate   KClO~3~                                                

  Magnesium                                                                   

  Titanium\*\*\*\*\*                                                          
  See Note                                                                    
  -------------------- -------------- ------- ------- ------- ------- ------- -------

**NOTE(s):**

> **\*\*\*\*** titanium **-** particle size must be larger than 149
> microns
>
> **\*\*\*\*** particle size must be provided for all metals in the
> Fireworks (EX) Approval Application

**DIAGRAM OF DEVICE**

**(note: include and mark all dimensions, fusing sequence, external
ignition fuse, empty tubes, effects)**

**Item Name:** \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **This is a
series application (Y/N): \_\_\_\_\_\_\_\_\_**

[^1]:
    > \(1\) The above list is from Table 4.3-1 of APA Standard 87-1,
    > \"Standard Fireworks Chemicals\".
    >
    > \(2\) Each chemical must be listed in Table 4.3-1
    >
    > \(3\) For specifics on the Restricted Chemicals, see APA Standard
    > 87-1