Statement Of Intended Use

27 CFR 55.103(d)

This statement has been submitted to comply with BATFE rules and regulations. By signing this document the below listed BATFE permit holder is stating that all regulated products purchased from QuickBurst are intended solely for use in model rocketry. Any other use would be a violation of this statement.

Name (print): ____________________________________

Address (Street, City, State and Zipcode):

Street: __________________________________

City: __________________________________

State: _____________________, ____________

SS#: ________ ________ ________ ________

Date Of Birth: ______ / ______ / ______

Place Of Birth: ______________________________

QuickBurst

59 Elm CT

Lake Jackson, TX 77566

Permit# 5-TX-039-21-OC-01178