Form Abc-1030 - Kansas Manufacturer Application For Brand Registration And Label Approval Page 5
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6Kansas 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
KANSAS MANUFACTURER
APPLICATION FOR BRAND REGISTRATION AND LABEL APPROVAL
SECTION 1 – MANUFACTURER INFORMATION
Manufacturer Name
License No.
Business Mailing Address
City
State
Zip Code
Contact Person
Title of Contact Person
Telephone Number
FAX Number
E-Mail Address
SECTION 2 – TRANSACTION REQUESTED*
New Brand Registration and New Label Approval $25 each label x _____ labels = $______
New Label Approval Request
$25 each label x _____ labels = $______
New Label Approval Request for Seasonal or
$25 each label x _____ labels = $______
Promotional Package
Effective Dates From__________ To ____________
New Package Configuration
(No charge)
Label Revision Request
$25 each label x _____ labels = $______
Inactivate Label(s)
(No charge)
Cancel Brand and all Labels
(No charge)
Other__________________________________ TOTAL LABELS ________ TOTAL FEE $____________
* SUBMIT ONLY ONE TRANSACTION TYPE PER FORM
FOR DEPARTMENT USE ONLY
Total Label Approval Fees Received: $
Date:
Initials:
Number of Labels Approved:
X $25 =
Additional Fees Due:
NO
YES
Refund Due:
NO
YES
Amount $
Number of Labels Denied:
Reason:
Signed:
Date:
ABC-1030 (Rev. 7.1.11)
Page 5 of 6
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