A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
STATE OF KANSAS
D
EPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
REQUEST FOR APPROVAL
OF MIXED ALCOHOLIC LIQUOR SERVED IN PITCHERS
WHO MAY COMPLETE THIS FORM?
Any On-Premise licensee seeking approval from the Director for the sale and service in a pitcher of mixed alcoholic beverages that are not currently approved
may complete and submit this form to the address or fax number above to request approval from the Director of ABC.
List only one type of mixed alcoholic beverages per request.
If the request is approved, it will be posted to our website at http://www.ksrevenue.org/abconprem.html
LICENSEE INFORMATION:
Organization Name License Number
Licensee Mailing Address City State Zip Code
Contact Person Name E-mail Address
Phone Number Fax Number
Requested by Name (please print)
Pitcher Information: (Enter the name of the mixed beverage and description, if any, in the space below.)
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
Signature of ABC Director Date
☐APPROVED
☐DENIED
Notified by ☐E-mail ☐Mail ☐Fax
Approved Pitchers Only ☐Posted to ABC Website
click to sign
signature
click to edit
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