Form Abc-41 - Kansas Department Of Revenue
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1
2Alcoholic Beverage Control
phone: 785-296-7015
915 SW Harrison St.
fax: 785-296-7185
Topeka, KS 66625-3512
Nick Jordan, Secretary
Sam Brownback, Governor
Dean Reynoldson, Director
I. Taxpayer/Licensee Information:
Name of Business: _____________________________________________________________________
Name of Owner: ________________________________________ License #: _____________________
Business Location: ____________________________________________________________________
City, State, Zip: ________________________________________ Contact Phone #: ________________
Mailing Information:
II.
(Complete if different from address given above.)
_____________________________________________________________________________________
Name
_____________________________________________________________________________________
Address
City, State and Zip Code
Record(s) being requested:
III.
(There is a fee for each item requested, if fee is not listed see page 2 of this form.)
(Y
)
(Y
)
(Y
)
(F
)
EAR
EAR
EAR
EE
θ
Liquor License Application
______
______
______
$5.25
θ
License Bond
______
______
______
$5.25
7. θ Other: ______________________________________________________
_______________________________________________________________
$ 5.25
X
________ =
__________
_______________________________________________________________
Total:
__________
_______________________________________________________________
Signature – Before signing this document, read this section carefully.
IV.
I request the Director of Alcoholic Beverage Control and/or the Director of Taxation furnish me with a copy of
items checked above. Under the penalties of perjury, I declare that the information I have furnished above, to the
best of my knowledge, is true, correct and complete. I further declare that I am the taxpayer/licensee, or the officer
for the taxpayer/licensee and have authorization to receive this information.
_______________________________________________
_______________________________________________
Printed Name and Title
Name of Your Business
_______________________________________________
_______________________________________________
Signature
Date
ABC-41
1
Rev. 07/11
Rev. 10/12
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