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Form Abc-816 (10.5.12) - Request For Temporary Extension Of Premise Approval Instructions - 2012 Page 3

Kansas Department of Revenue

Alcoholic Beverage Control Division

915 SW Harrison Street

Topeka, KS 66625-3512

Phone: 785-296-7015 Fax: 866-855-5025

Zoning:

CERTIFICATE OF CITY, TOWNSHIP OR COUNTY CLERK

I HEREBY CERTIFY THAT THE PREMISES AT _______________________________________________________________IS:

Location Street Address

City

Zip

(check one box in each section):

CITY LIMITS:

Inside the incorporated city limits

Outside the city limits

PREMISE:

complies with all local ordinances/resolutions concerning the sale and consumption of alcoholic liquor.

(Seal)

CLERK SIGNATURE ______________________________________

City Clerk

Township Clerk

County Clerk

PRINTED NAME__________________________________________

DATE________________ PHONE________________________

I understand that I must maintain a copy of the approved diagram on the licensed premise and make available for immediate

inspection upon request.

Under penalties of perjury, I declare the information contained in this document a true, accurate and complete

disclosure of information.

Licensee Signature

Printed Name

Date

ABC Office Use Only

DIAGRAM APPROVED AS SUBMITTED

Signature of ABC Official

Date

DIAGRAM DENIED

Reason Denied:

Clear Form

ABC-816 (10.5.12)

Page 3 of 3

Form Abc-816 (10.5.12) - Request For Temporary Extension Of Premise Approval Instructions - 2012 Page 3