Form Abc-816 (10.5.12) - Request For Temporary Extension Of Premise Approval Instructions - 2012 Page 2
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1
2
3Kansas Department of Revenue
Alcoholic Beverage Control Division
915 SW Harrison Street
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 866-855-5025
REQUEST FOR TEMPORARY EXTENSION OF PREMISE APPROVAL
Licensee Information:
Business DBA Name
License Number
Business Location Street Address
City
Zip Code
Contact Person Name
Phone Number
Email Address
Event Date(s)
Event Start Time(s)
Event End Time(s)
Is the area of the extension request under the control of the licensee?
Yes
No
If no, I have attached written permission from the owner or the city/county. (Required).
Yes
No
Diagram:
Check the appropriate box then draw a complete diagram of the premises for which you are seeking approval or attach your drawing.
The
diagram must indicate the current premise and the temporary extension area. Architectural drawings are not accepted
if larger
than 8 ½” X 11”.
Check one:
Diagram drawn below
8 ½” X 11” drawing attached
ABC-816 (10.5.12)
Page 2 of 3
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