Retail Registration Form

The filing of this application or the granting of a retail license neither confirms nor denies the use of land as regulated under the zoning ordinance.

Information provided on this application may be forwarded to the Kansas Department of Revenue for the purpose of verifying compliance with the provisions of the Kansas Retailers Sales Tax Act, K.S.A. 79-3601 et seq., as amended.  Such information shall be subject to the confidentiality provisions set forth in K.S.A. 79-3614.

Business Information
Owner / Contact Information
Please include name, address, title, and phone
Emergency Information
Please include name & phone number
Agreement
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