KANSAS DEPARTMENT OF REVENUE Alcoholic Beverage Control Division ZONING Applicant/Owner Name:_________________________________________________ Type of License Sought: Retail Liquor Store Private Club: A or Caterer Distributor Drinking Establishment Hotel Hotel/Caterer Temporary Permit B Drinking Establishment/Caterer Hotel/Drinking Establishment Farm Winery Outlet Microbrewery Packaging/Warehouse Manufacturer PREMISES TO BE LICENSED ______________________________________________________________________________________ DBA Name of business ______________________________________________________________________________________ Location Address ______________________________________________________________________________________ City Township County Zip NOTICE TO CITY/COUNTY CLERK: Submission of this zoning form by the applicant to the City or County constitutes notification to the governmental entity that an application for a liquor license has been or will be received by the ABC. Should the city or county you represent desire to make any comments, suggestions or recommendations relative to the granting of or refusal to grant a license to the above-named applicant or the premise for which licensure is sought – or to request a hearing pursuant to K.S.A. 41-318 or 41-2651 – it may do so by mailing such information to the ABC within 10 days of the date you affix your seal to this document at: ABC, New Applications, 915 SW Harrison St., Rm. 214, Topeka KS 66625-3512. CERTIFICATE OF CITY, TOWNSHIP OR COUNTY CLERK STATE OF KANSAS, COUNTY OF _________________________________________, SS: I HEREBY CERTIFY THAT (check applicable box): The premises described above are inside the incorporated city limits; or, The premises described above are outside the city limits.* *For RETAIL LIQUOR STORES ONLY: Per K.S.A. 41-303, no license shall be granted to any applicant unless 1) the premise to be licensed is located in a township with a population of at least 5,000; AND 2) the board of county commissioners has adopted a resolution approving the issuance of a license to the location. A certified copy of such resolution must accompany the license application. AND (check applicable box): The premises described above are within an area that complies with all applicable zoning regulations required by K.S.A. 41-710 or K.S.A. 41-2608. Farm Wineries and Microbreweries must be zoned agricultural, commercial or business as required by K.S.A. 41-710(b) AND if the license type is a Retail Liquor Store, Farm Winery or Microbrewery, the premises complies with the applicable building regulations per K.S.A. 41-710. The premises described above are located outside an incorporated city, in a township or county that is not zoned. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal this ________ day of ________________________________, __________. (month) (year) ________________________________ City, Township or County Clerk (Circle one) ______________________________________ (Seal) ABC-280-8 Rev 10/08 Phone number of City, Township or County Clerk American LegalNet, Inc. www.FormsWorkflow.com