The purchaser form for each retail or wholesale sale of fireworks to both residents and non-residents of this state shall be prescribed by the state fire marshal and provided by the seller to each purchaser. A copy of the purchaser form utilized by each seller shall be provided to the state fire marshal upon request. The form shall include, but not be limited to, the following information:
(a) The purchaser’s name and address;
(b) The date of the purchase;
(c) A statement that the purchaser acknowledges that the purchaser is responsible for any illegal use of the fireworks, including any damages caused by their improper use;
(d) For a sale to a manufacturer, the name of the state and number of the purchaser’s license or permit from that state or other verifying information authorizing the purchaser to manufacture;
(e) For a sale to a wholesaler, the name of the state and the number of the purchaser’s license or permit from that state or other verifying information authorizing the purchaser to sell at wholesale;
(f) For a sale to an exhibitor from another state, the name of the state and the number of the purchaser’s license or other verifying information authorizing the purchaser to conduct fireworks exhibitions, and, if applicable the permit information for the exhibition for which the fireworks are being purchased;
(g) For a sale at retail to an individual other than a wholesaler, manufacturer or exhibitor, the number of the purchaser’s motor vehicle operator’s license or other valid state issued identification card;
(h) The purchaser’s signature;
(i) A statement printed in bold letters indicating that knowingly making a false statement on the purchaser’s form is falsification under section 2921.13 of the Revised Code and is a misdemeanor of the first degree; and
(j) Such other information as the state fire marshal may require.