Kathleen Sebelius, Governor Joan Wagnon, Secretary www.ksrevenue.org ______________________________________________________________________ REGISTRATION OF DELIVERY VEHICLES Retail Liquor Licensee For the purpose of qualifying to carry liquor in vehicle(s) listed below and issuance of a vehicle identification card, the licensee certifies and warrants that the statements and representations made herein are true and correct. If any statement or representations are herein found to be false, the director may refuse to issue a vehicle identification card or may cause the card to be relinquished at any time. LICENSE NUMBER:___ ___ - ___ ___ ___ - ___ ___ ___ ___ - ___ ___ RETAIL LIQUOR STORE NAME:____________________________________________ OWNER NAME:_________________________________________________________ ADDRESS:_____________________________________________________________ CITY:__________________________________________KS ZIP CODE:____________ PHONE:________________________________________________________________ List all vehicles which will be used to transport alcoholic liquor below: Make Year Vehicle Identification Number I agree, if issued vehicle identification cards, to abide by the provisions of the Kansas Liquor Control Act and the rules and regulations thereunder in the transportation of alcoholic liquor in Kansas. _________________________________________________________________________ Licensee Signature Date DIVISION OF ALCOHOLIC BEVERAGE CONTROL DOCKING STATE OFFICE BUILDING, 915 SW HARRISON ST., TOPEKA, KS 66625-3512 Voice 785-296-7015 Fax 785-296-7185 http://www.ksrevenue.org/abc.htm ABC-103-R (Rev. 5.10.07) American LegalNet, Inc. www.FormsWorkflow.com