Form Abc-830 - Temporary Permit Application And Agreement Instructions Page 4
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6Kansas Department of Revenue
Alcoholic Beverage Control Division
915 S.W. Harrison Street, Room 214
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 785-296-7185
TEMPORARY PERMIT APPLICATION AND AGREEMENT
Event Type:
Charitable Auction
On-Premise Temporary Permit
Porcelain Container
Special Event Permit*
*A special event is held on public streets, alleys, roads, sidewalks or highways when a temporary permit has been issued pursuant to K.S.A. 41-
2645 for such special event. Such special event must be approved, by ordinance or resolution, by the local governing body of any city, county or
township where such special event is being held. No alcoholic liquor may be consumed inside vehicles while on public streets, alleys, roads or
highways at any such special event. The permit may be issued for up to 30 consecutive days,with the Director’s approval.
Event Length:
1 Day Permit - $25
2 Day Permit - $50
3 Day Permit - $75
Special Event Only – Number of Consecutive days (up to 30):_________ X $25 per day = $ _________ Total Due
Special Event Only:
Resolution or Ordinance attached
SECTION 1 – APPLICANT INFORMATION:
Entity Type:
Corporation
Individual
Organization
Partnership
Association
Other:_______________________
Have you previously applied for a temporary permit this calendar year?
No
Yes, I have had _____ temporary permits this calendar year.
Individual Applicant or Organization Name
Contact Person
Phone
Fax
Mailing Address
City
County
Zip Code
DESIGNATED PERSON
Designated Person Name
Date of Birth
Social Security Number
Phone
Email Address
SECTION 2 – EVENT INFORMATION:
(You may have up to three consecutive days per permit. Special events may be up to 30 days).
Purpose for which the proceeds from this event will be used:
Does this location have a state issued liquor license or a Cereal Malt Beverage License?
Yes
No
Event Location Address
City
County
Zip Code
Date of Event
From Time
AM
To Time
AM
PM
PM
Date of Event
From Time
AM
To Time
AM
PM
PM
Date of Event
From Time
AM
To Time
AM
PM
PM
SECTION 3 – PURCHASE INFORMATION:
(Complete information below to indicate where you are purchasing liquor).
Kansas Retailer DBA Name
Kansas Retailer License No.
Retailer’s Federal Wholesale Liquor Dealer
Permit No.
Kansas Farm Winery DBA Name
Kansas Farm Winery License No.
SECTION 4 – CERTIFICATE OF CITY, TOWNSHIP OR COUNTY CLERK:
(Completed by the clerk).
I HEREBY CERTIFY THAT THE LOCATION DESCRIBED ABOVE IN SECTION 2 IS: (check one box in each section):
CITY LIMITS:
Inside the incorporated city limits
Outside the city limits
ZONING:
within an area that complies with all applicable zoning regulations required by K.S.A. 41-710
located outside an incorporated city, in a township or county that is not zoned
(Seal)
LOCATION:
government property
private property
public property
CMB licensed premise
I declare under penalties of perjury that to the best of my knowledge and belief that Section 4 is true, correct and complete.
CLERK SIGNATURE ______________________________________
DATE______________________PHONE____________________
PRINTED NAME_________________________________________
City Clerk
Township Clerk
County Clerk
ABC-830 (Rev. 7.1.12)
Page 4 of 6
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