Form Abc-828 - Kansas Packaging And Warehousing Facility Permit Application And Agreement Page 2
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2Kansas 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 PACKAGING AND WAREHOUSING FACILITY PERMIT
APPLICATION AND AGREEMENT
Permit Type (check one):
New Permit
Renew Permit
Applicant Entity Type (check one):
Individual
Corporation
Partnership
LLC
LLP
Permit Number (renew permit only)
FEIN
Phone
25-
DBA Name
Entity Name
Location Address
City
State
Zip
Mailing Address
City
State
Zip
Contact Person
E-mail Address
Compliance Agency Name
Does your company use a compliance agency?
Yes*
No
*If yes, complete the compliance agency information.
Compliance Agency Mailing Address
City
State
Zip
Compliance Agency Contact Person Name
Compliance Agency Phone
The above named manufacturer or supplier does hereby make application for a Packaging and Warehousing Facility
Permit. In making this application, the above named manufacturer or supplier agrees that:
a. It may transfer alcoholic liquor or cereal malt beverage to the licensed premises of a packaging and
warehousing facility for the purpose of packaging or storage or both.
b. It may sell and transfer from the licensed premises of a packaging and warehousing facility to the licensed
premises of a spirits, wine or beer distributor licensed in Kansas or to a Kansas supplier.
c. It may transfer from the licensed premises of a packaging and warehousing facility to another state.
d. It will register with the Director each brand and label of alcoholic liquor and/or cereal malt beverage transported
to or stored at a licensed packaging and warehousing facility that is intended for sale to distributors in Kansas
prior to making shipments to licensed distributors in this state.
e. It hereby appoints the Kansas Secretary of State its resident agent and representative authorized to accept
service of any notice or order and that all such acts by the Secretary of State shall be fully binding upon the
manufacturer or supplier.
f.
It will abide by all the provisions of the Kansas Liquor Control Act and the Rules and Regulations promulgated
thereunder.
________________________________________
________________________________________
Authorized Signature
Date
________________________________________
________________________________________
Printed Name
Printed Title
FOR OFFICE USE ONLY:
$2500 Permit Fee Received Date ____________ Initials ___________
New Permit Approved Date ______________ Expires ____________ Completed by:____________ Date: ______________
Renew Permit From ____________ to ____________
Completed by:____________ Date: ______________
ABC-828 (Rev. 7.1.11)
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