Form Abc 170 - Keg Registration Form

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Kansas 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 REGISTRATION FORM
Kansas state law requires any individual purchasing a container or keg having the capacity of four or
more gallons of beer or cereal malt beverage at retail to complete this form and provide the retailer
from whom purchased with valid photo identification. This form may be returned to the purchaser or
destroyed upon return of the container or keg to the retailer.
Retailer Information:
Attach Keg Number(s) here
Date of Sale:
DBA Name:
Product Information:
Product Name:
Product Size:
Keg ID Number:
Purchaser Information:
Name:
Street Address:
City / State / Zip:
Valid Identification:
Identification Type:
Number:
Date of Birth:
Certification:
I certify that the information contained on this form is true and correct to the best of my knowledge and
belief, and that I am of legal age to purchase, possess and consume beer or cereal malt beverage. I
also understand that it is unlawful to resell this product, allow consumption of the product by any
person who is not of legal age or to remove the numbered label/tag attached to the keg(s).
________________________________________________________________
Signature of Purchaser
Date
ABC 170 (Rev. 7.1.11)

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