ALCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
TOPEKA KS 66601-3506
STATE OF KANSAS
DEPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
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.
Attach Keg Number(s) here
Retailer Information:
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. 02/18)
click to sign
signature
click to edit
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