Form Abc-843 - Request To Temporarily Surrender Liquor License
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1Kansas Department of Revenue
Alcoholic Beverage Control Division
915 SW Harrison Street
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 866-855-5025
REQUEST TO TEMPORARILY SURRENDER LIQUOR LICENSE
Licensees must complete and submit this form for approval if they wish to surrender all or part of their liquor license for an event.
Your request may be sent by fax, mail or e-mail to
abc.licensing@kdor.ks.gov
and must be received by the ABC Director at least 10
days prior to surrendering your liquor license.
Licensee Information:
Licensee DBA Name
License Number
Address
City
Requestor Name
Requestor Title
Phone Number
E-mail Address
License Surrender Information:
Date(s)
Date(s) of Surrender:
Start Time
End Time
Hours of Surrender:
Date
Time
Normal activities will resume:
Area of Surrender:
I am surrendering the entire licensed premise.
I am surrendering part of my licensed premise. I have drawn in the space below, in ink, a complete sketch of the licensed
premises and shaded the area which is being surrendered. Include all entrance, exit and interior doors, walls, etc.
I understand that no alcoholic liquor or cereal malt beverage may be sold or dispensed by the licensee during the date(s) and
time(s) indicated above.
Under penalties of perjury, I declare the information contained in this document a true, accurate and complete
disclosure of information.
Authorized Signature
Date
ABC Office Use Only
Received less than 10 days in advance of event.
APPROVED
Notified Licensee via:
Email
Fax
Mail
Signature of ABC Official
Date
DENIED
Notified Enforcement via email:
Yes
ABC-843 (4.3.13)
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Parent category: Financial