STATE OF KANSAS
A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
D
EPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
NON-BEVERAGE PERMIT APPLICATION AND AGREEMENT
APPLICANT TYPE (check one):
☐College ☐Hospital ☐Sanatorium ☐School ☐Other institution caring for the sick
SECTION 1 – APPLICATION INFORMATION:
Applicant DBA Name FEIN
Street Address City County State Zip Code
Applicant Contact Person Phone Number Fax Number E-mail Address
Mailing Address
(Complete if different than above.)
Name
Mailing Address City State Zip Code
SECTION 2 – PURCHASE INFORMATION:
PURPOSE (check one):
☐Scientific ☐Chemical ☐Experimental ☐Mechanical ☐Medicinal
I/We intend to purchase from a (check one):
☐Distributor ☐Farm Winery ☐Manufacturer ☐Microbrewery ☐Microdistillery
The above Distributor, Farm Winery, Manufacturer, Microbrewery or Microdistillery is located (check one):
☐In-State ☐Out-of-State
Location where alcohol or wine will be stored:
The above named school, college, hospital, sanatorium or institution caring for the sick, does hereby make application for a Non-Beverage User Permit to purchase
alcohol or wine. In making this application, the above named Non-Beverage Permit applicant agrees that they will:
a. M
ake a one-time purchase of alcohol or wine only for scientific, chemical, experimental, mechanical or medicinal purposes.
b. Forward two copies of their Non-Beverage Permit to the Distributor, Farm Winery, Manufacturer, Microbrewery or Microdistillery from whom they are purchasing
alcohol or wine.
c. Not use, serve or sell the alcohol or wine that is purchased under this permit for human consumption.
d. Attach the invoice to their permit and return it to the ABC within 10 days of receipt of alcohol or wine.
e. Comply with applicable city and county laws; and, with all the provisions of the Kansas Liquor Control Act, Club and Drinking Establishment Act and the Rules and
Regulations promulgated thereunder.
f. Authorize the Kansas Department of Revenue to send communications to the e-mail address provided on this form.
Under penalties of perjury, I declare the information contained in this document a true, accurate and complete disclosure of information.
Authorized Signature Date
Printed Name Printed Title
ABC OFFICE USE ONLY:
☐ PERMIT FEE ENCLOSED Amount $ Associate: Date
☐ APPROVED Date Associate: Permit #
☐ DENIED Date Associate: ☐Denial Letter Sent Date
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