Form Abc 171 - Keg Tag Order Form
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1Kansas Department of Revenue
Alcoholic Beverage Control Division
915 S.W. Harrison Street, Room 214
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 785-296-7185
KEG TAG ORDER FORM
Please complete and return this form to order keg tags.
Check one:
Retail Liquor Store
Microbrewery
Cereal Malt Beverage Retailer
Military Retailer
Retailer Information:
Owner Name:
DBA Name:
License Number / CMB Stamp Number / ATF Number:
Address:
City / State / Zip:
Phone:
Fax:
Mailing Information:
(if different from retailer address)
Name:
Address:
City / State / Zip:
Order Information:
Quantity of Tags Requested:
Name of Person Requesting Tags:
_________________________________________________________________________
Signature of Person Requesting Keg Tags
Date
ABC Office Use Only:
Keg Tag Numbers Issued: Starting #:
Ending #:
Quantity Issued:
Date Issued:
Issued By:
ABC 171 (Rev. 7.1.11)
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