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 TO TEMPORARILY SURRENDER LIQUOR LICENSE
Licensees must complete and submit this form for approval if they wish to surrender all or part of their liquor license for an event. Your request may be sent by fax, mail
or e-mail to KDOR_ABC.Licensing@ks.gov and must be received by the ABC Director at least 10 day prior to surrendering your liquor license.
Licensee Information:
Licensee DBA Name License Number
Address City State Zip Code
Requestor Name Requestor Title
Phone Number E-mail Address
License Surrender Information:
Date(s) of Surrender:
Date(s)
Hours of Surrender:
Start Time End Time
Normal club activities will resume:
Date Time
Area of Surrender:
☐ I am surrendering the entire licensed premise.
☐
I am surrendering part of my licensed premise. I have drawn in the space below, in ink, a complete sketch of the licensed premises and shaded the area which is
being surrendered. 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.
☐ I understand all liquor and invoices must be locked in an area not accessible by the public during this event.
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
☐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 Date
click to sign
signature
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