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: Qualifications of Fireworlcs/Pyrotechnics Operators <br /> • <br /> f 1 y- fa ll , ; Please Type or Print In Ink To Fill Out This Form <br /> Name: Chris Reitano <br /> Address: 18405 Normandeau Street <br /> City: Springs Hill State: FL Zip: 34610 <br /> Age: 36 Date of Birth: 3 / 9 / 74 <br /> Social Security Number: 267 -63 -3577 <br /> FLORIDA <br /> XMOi'i+i(License Number: 1 FL00366 <br /> List of most current previous shows: <br /> 1. City of Ft. Lauderdale, FL Date: 12/31/09 <br /> 2. City of Boca Raton, FL Date: 12/19/09 <br /> 3, Coconut Festival, Cape Coral, FL <br /> Date: 11/13 & 11/14,09 <br /> 4 Vero Beach High School, FL <br /> Date: 10/29 & 10/30,09 <br /> S Gator Growl, Univ. of Florida 10/16/09 <br /> Date: <br /> Please list below any injuries and amounts of any property damages and location of show <br /> that may have occurred at any previous shows: <br /> i <br /> Signature of Operator: 67,,u_ot <br />