Form Abc-830 - Temporary Permit Application And Agreement Instructions Page 5
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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
Applicant or Organization Name________________________________________ Event Date(s)________________________
SECTION 5 – BACKGROUND QUALIFICATIONS:
Applies to yourself and any person in the sponsoring organization.
If the answer to any question is yes, provide explanation on separate page and attach to your application.
1. Have you or any person in the sponsoring organization been convicted of or pled guilty to a felony?
Yes
No
2. Have you or any person in the sponsoring organization been convicted of or pled guilty to a morals charge?
Yes
No
(Morals charge includes: prostitution; procuring any person; solicitation of a child under 18 for immoral act involving sex; possession or sales of narcotics;
marijuana; amphetamines or barbiturates; rape, incest; gambling; adultery; bigamy).
3. Have you or any person in the sponsoring organization had an alcoholic liquor or cereal malt beverage license revoked
Yes
No
in Kansas or in any state?
SECTION 6 – DIAGRAM:
Complete for On-Premise and Special Events only.
Draw in the space below, in ink, a complete sketch of the premises which you are seeking approval. The diagram must include all entrance and
exit doors; and, bar area. Architectural drawings are not accepted.
ABC-830 (Rev. 7.1.12)
Page 5 of 6
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