A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
STATE OF KANSAS
DEPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
REQUEST FOR PUBLIC FUNCTION
Class A or Class B Clubs wanting to use part of their licensed premises for a public event must first get approval from the Director of ABC. For approval, complete and
return this form to the address or fax number above. Your request must be received by the ABC Director at least 10 days prior to the public function.
Licensee Information:
Licensee DBA Name License Number
Address City State Zip Code
Requestor Name Requestor Title
Phone Number E-mail Address
Public Function Information:
Type of Public Function:
Conducted by Whom:
Date(s) of Public Function:
Time(s) of Public Function:
Normal club activities will resume:
Date Time
Diagram:
In the space below, in ink, draw a complete sketch of your licensed premises and shade the area which you are seeking approval of a public function. The diagram
must include all entrance, exit and interior doors, walls, etc.
☐ I understand that no alcoholic liquor or cereal malt beverage may be sold, dispensed or consumed by anyone in the area described during the time(s) indicated.
Under penalties of perjury, I declare the information contained in this document a true, accurate and complete disclosure of information.
Requester Signature Date
ABC Office Use Only
☐
Received less than 10 days in advance of event. May be subject to administrative action.
☐APPROVED
☐DENIED
Notified Licensee via: ☐E-mail ☐FAX ☐Mail
Notified Enforcement via e-mail: ☐Yes
Signature of ABC Official
click to sign
signature
click to edit
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