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Form Abc-1020 - Kansas Microbrewery - Application For Brand Registration And Label Approval Page 4

Kansas 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

KANSAS MICROBREWERY

APPLICATION FOR BRAND REGISTRATION AND LABEL APPROVAL

SECTION 1 – LICENSEE INFORMATION

Microbrewery Name

License No.

Business Mailing Address

City

State

Zip Code

Contact Person

Title of Contact Person

Telephone Number

FAX Number

E-Mail Address

SECTION 2 – TRANSACTION REQUESTED*

New Brand Registration and New Label Approval

New Label Approval Request

New Package Configuration

Seasonal or Promotional Package Approval Request

Effective From :_______________ Effective To: ________________

Label Revision Request

Inactivate Label(s)

Cancel Brand and all Labels

Other__________________________________

TOTAL LABEL APPROVALS REQUESTED __________

* SUBMIT ONLY ONE TRANSACTION TYPE PER FORM

FOR DEPARTMENT USE ONLY

Number of Labels Approved:

Number of Labels Denied:

Reason:

Signed:

Date:

ABC-1020 (Rev. 7.1.11)

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Form Abc-1020 - Kansas Microbrewery - Application For Brand Registration And Label Approval Page 4