Individual/sole Proprietor Application For License To Sell Cereal Malt Beverages
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1
2INDIVIDUAL/SOLE PROPRIETOR
APPLICATION FOR LICENSE TO SELL CEREAL MALT BEVERAGES
(This form has been prepared by the Attorney General’s Office)
City or
County of ______________________________________________________________________
SECTION 1 – LICENSE TYPE
Check One:
New License
Renew License
Special Event Permit
Check One:
License to sell cereal malt beverages for consumption on the premises.
License to sell cereal malt beverages in original and unopened containers and not for consumption on
the licenses premises.
SECTION 2 – APPLICANT INFORMATION
Kansas Sales Tax Registration Number (required):
Name
Phone No.
Date of Birth
Residence Street Address
City
Zip Code
Applicant Spousal Information
Spouse Name
Phone No.
Date of Birth
Residence Street Address
City
Zip Code
SECTION 3 – LICENSED PREMISE
Licensed Premise
Mailing Address
(Business Location or Location of Special Event)
(If different from business address)
DBA Name
Name
Business Location Address
Address
City
State
Zip
City
State
Zip
Business Phone No.
I own the proposed business location.
I do not own the proposed business location.
Business Location Owner Name(s)
SECTION 4 – APPLICANT QUALIFICATION
I am a U.S. Citizen
Yes
No
I have been a resident of Kansas for at least one year prior to application.
Yes
No
I have resided within the state of Kansas for ______________ years.
I am at least 21 years old.
Yes
No
I have been a resident of this county for at least 6 months.
Yes
No
1
Within 2 years immediately preceding the date of this application, neither I nor my spouse
has
been convicted of, released from incarceration for or released from probation or parole for any
of the following crimes:
Yes
No
(1) Any felony; (2) a crime involving moral turpitude; (3) drunkenness: (4) driving a motor
vehicle while under the influence of alcohol (DUI); or (5) violation of any state or federal
intoxicating liquor law.
My spouse has previously held a CMB license.
Yes
No
My spouse has never been convicted of one of the crimes mentioned above while licensed.
Yes
No
Page 1 of 2
AG CMB Individual Application (Rev. 07.08.2013)
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