Fees will increase September 1, 2003. If you file this report
before September 1, the fee is $25.00. If you file this report after
September 1, the fee is $40.00.
Contact Information
KANSAS SECRETARY OF STATE
BW
Bonded Warehouse License Application
Kansas Secretary of State
Ron Thornburgh
55
Memorial Hall, 1st Floor
All information must be completed or this document will not be accepted for filing.
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
Print
Reset
1. Name of the applicant: __________________________________
Please complete the form, print, sign and
mail to the Kansas Secretary of State with
_______________________________________________________
the filing fee. Selecting 'Print' will print
Street address
the form and 'Reset' will clear the entire
___________________________ _____________ ____________
form.
State
Zip
City
(The applicant’s name must be identical on both the application and the bond.)
Do not write in this space
2. If the applicant is a corporation, list the names and addresses of the officers and directors below. If the applicant is a partnership, list
the names and addresses of the partners below.
Name
Title
Street address
City
State
Zip
3. Place(s) of business where the applicant will operate as a bonded warehouse.
Street address
City
State
Zip
Maximum value of property by the applicant stored at any time during the period for which this application is effective, not including
property owned by the applicant, $ _________________ .
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the _________ of _____________ , __________
.
Day
Month
Year
Signature
Instructions
1. Submit this form with bond and the $40 filing fee.
2. All licenses expire on December 31 of each year. A new application and bond must be submitted annually.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 amc
K.S.A. 82-163