Form Abc-1000 - Supplier Permit Fee Voucher Page 2
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2Kansas 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
SUPPLIER PERMIT APPLICATION AND AGREEMENT
Permit Type (check one):
New Permit
Renew Permit
Is your company located in Kansas?
No
Yes
Applicant Entity Type (check one):
Individual
Corporation
Partnership
LLC
LLP
Supplier Permit Number (renewals only)
FEIN
Phone
19-
Supplier DBA Name
Supplier Entity Name
Location Address
City
State
Zip
Mailing Address
City
State
Zip
Contact Person
E-mail Address
Compliance Agency Name
Does your company use a compliance agency?
Yes*
No
*If yes, complete the compliance agency information.
Compliance Agency Mailing Address
Compliance Agency City
State
Zip
Compliance Agency Contact Person Name
Compliance Agency Phone
The above named Brewer, Importer, Out-of-State Manufacturer or Vendor, hereafter referred to as “supplier”, does hereby
make application for a Supplier Permit to sell alcoholic liquor and/or cereal malt beverage to licensed distributors or non
beverage users in the State of Kansas. In making this application, the above named supplier agrees that:
a.
It will not ship, sell, attempt to sell or deliver any alcoholic liquor and/or cereal malt beverage within the State of
Kansas except to a licensed distributor, manufacturer or non-beverage user.
b.
It will not ship, sell, attempt to sell or deliver any alcoholic liquor and/or cereal malt beverage to any distributor who
does not possess a franchise for such merchandise; and that all such sales to franchised distributors in the State of
Kansas will be at the same price and without discrimination.
c.
It will register each brand of alcoholic liquor and/or cereal malt beverage with the Director prior to making shipments
to distributors in this state.
d.
It will register and pay an annual fee in the amount of $25 for each label of alcoholic liquor and cereal malt beverage
proposed for sale in this state.
e.
It will submit monthly reports as required by the Director.
f.
It hereby appoints the Secretary of the State of Kansas its resident agent and representative authorized to accept
service of any notice or order and that all such acts by the Secretary of State shall be fully binding upon the supplier.
g.
It will abide by all the provisions of the Kansas Liquor Control Act and the Rules and Regulations promulgated
thereunder.
________________________________________
________________________________________
Authorized Signature
Date
__________________
_________
_____________
__________________
_________
_____________
Printed Name
Printed Title
MAKE A COPY FOR YOUR RECORDS
You will NOT receive a permit or certificate. Your copy will serve as your permit.
FOR OFFICE USE ONLY:
$25 Permit Fee Received Date
____________
New Permit Approved Date
______________
Expires June 30, 20
_____
Renew Permit From July 1, 20
_________
to June 30, 20
_________
____________
Date:
______________
Completed by:
ABC-1000 (Rev. 7.19.13)
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