Individual/sole Proprietor Application For License To Sell Cereal Malt Beverages Page 2
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1
2INDIVIDUAL/SOLE PROPRIETOR
APPLICATION FOR LICENSE TO SELL CEREAL MALT BEVERAGES
(This form prepared by the Attorney General’s Office)
SECTION 5 – MANAGER OR AGENT QUALIFICATION
My place of business or special event will be conducted by a manager or agent.
Yes
No
If yes, provide the following:
Manager/Agent Name
Phone No.
Date of Birth
Residence Street Address
City
Zip Code
Manager or Agent Spousal Information
Spouse Name
Phone No.
Date of Birth
Residence Street Address
City
Zip Code
Qualification Statement
2
My manager/agent and his/her spouse
meets all of the qualifications in Section 4.
Yes
No
SECTION 6 – DURATION OF SPECIAL EVENT
Start Date
Time
AM
PM
End Date
Time
AM
PM
I declare under penalty of perjury under the laws of the State of Kansas that the foregoing is true
and correct. (K.S.A. 52-601)
SIGNATURE _________________________________________________ DATE ______________________
FOR CITY/COUNTY OFFICE USE ONLY:
License Fee Received Amount $____________ Date ____________
($25 - $50 for Off-Premise license or $25-200 On-Premise license)
$25 CMB Stamp Fee Received Date ____________
Background Investigation
Completed Date _____________
Qualified
Disqualified
New License Approved
Valid From Date _____________ to _____________ By: _____________
License Renewed
Valid From Date _____________ to _____________ By: _____________
Special Event Permit Approved
Valid From Date _____________ to _____________ By: _____________
A PHOTOCOPY OF THE COMPLETED FORM, TOGETHER WITH THE STAMP FEE REQUIRED BY K.S.A. 41-2702(e), MUST BE
SUBMITTED WITH YOUR QUARTERLY REPORT (ABC-307) TO THE ALCOHOLIC BEVERAGE CONTROL, 915 SW HARRISON
STREET ROOM 214, TOPEKA, KS 66625-3512.
1
If renewal application, applicant’s spouse not required to meet the no criminal history requirement. K.S.A. 41-2703(b)(9
2
Spouse not required to be U.S. citizen, Kansas resident or over 21 years of age. K.S.A. 41-2703(b)(9)
Page 2 of 2
AG CMB Individual Application (Rev. 07.08.2013)
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