Start date of temp permit Required Required End date of temp permit Required Required
Is Temporary Permit for a Temporary Entertainment District? Yes No Required Required

Business Entity Name * Required

Location DBA Name Required Required

Mailing City* Required Mailing State* Enter a Valid US State Required Mailing Zip* Minimum 5 characters required. Required

Name (First Middle Last)* Required
Address* PO Boxes are not allowed Required
City* Required State* Enter a Valid US State Required Zip* Minimum 5 characters required. Required
Primary Phone* Required Minimum 10 digit phone required. Primary owner’s phone cannot be the same as the additional contact’s phone. Minimum 10 digit phone required. Required Email* Please enter a valid e-mail address. Required

Birthplace* Required Ownership %* Required Marital Status* Required Driver's License Number* Required Maiden Name Required

Other Names Used Required

Contact Above's Spouse

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required
Date of Birth Required Last 4 of SSN Required Enter 4 digits Birthplace Required Ownership % Required Marital Status Required Required Driver's License Number Required Other Names Used Required Maiden Name Required

Owner2

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required

Contact Above's Spouse

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required

Owner 3

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Primary owner’s phone cannot be the same as the additional contact’s phone. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required

Contact Above's Spouse

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required

Owner 4

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required

Contact Above's Spouse

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required

Please upload a list of any additional owners*

Name* Required
Address* Required
City* Required State* Enter a Valid US State Required Zip* Minimum 5 characters required. Required
Primary Phone* Required Minimum 10 digit phone required. Primary owner’s phone cannot be the same as the additional contact’s phone. Minimum 10 digit phone required. Required Email* Please enter a valid e-mail address. Required
Date of Birth* Required

Process Agent Spousal Information

Name Required
Address Required
City Required State Enter a Valid US State Required Zip Minimum 5 characters required. Required
Primary Phone Required Minimum 10 digit phone required. Primary owner’s phone cannot be the same as the additional contact’s phone. Minimum 10 digit phone required. Required Email Please enter a valid e-mail address. Required
Date of Birth Required Last 4 of SSN Required Enter 4 digits Birthplace Required Required Marital Status Required Driver's License Number Required Other Names Used Required Maiden Name Required

Manager Information

Background Qualifications

1) Has any owner or processing agent been convicted of a felony in Kansas or in any other state, or under federal law?* * Yes No Required Required 2) Has any owner or processing agent been convicted of a morals charge (prostitution; procuring anyperson; solicitation of a child under 18 for immoral act involving sex; possession or sale of narcotics,marijuana, amphetamines or barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other state?* Yes No Required Required 4) Is any owner or processing agent currently a law enforcement officer or a non-elected official who supervises or appoints any law enforcement officer?* Yes No Required Required

Is your Corporation, Partnership, LLC or LLP in good standing pursuant to the laws of the state where entity is organized or incorporated? Yes No Required Required

7) Has the CPTED (Crime Prevention Through Environmental Design) inspection been scheduled?* Yes No Required

Please contact your Community Policing Officer at your local Police Substation.

Security Plan

A plan to ensure that adequate traffic control, crowd protection and security will be maintained and that ages of patrons admitted* Required Required An emergency management plan, consisting of, but not limited to: fire evacuation, storm shelter provisions, patron crowd* Required Required

Please upload copy of insurance coverage information* Required

Please upload a copy of any lease or purchase agreement for the licensed premises* Required

Please upload a floor plan (8 ½” x 11” only size accepted) of the licensed premises and a site plan showing the location of parking* Required

Please upload proof of approved capacity of 850 persons or more* Required

Please upload proof of a proper digital video surveillance cameras as required* Required

Please upload proof that all managers and employees of the establishment have successfully completed the Club Violence* Required

Please plan for how to check identification of patrons and the plan to visibly identify patrons who are of drinking age and* Required

Please uploadthe establishment’s pre-defined Security plans as approved by the WPD. Include proper Crowd Management and* Required

Please upload a copy of a food menu* Required

Please upload a statement of monthly projected income separating food and alcohol sales* Required

Please upload copies of food and alcohol vendor letters of intent* Required

License Type* Required License Number Required Issue Date Required

declare under penalty of perjury, the information in this application and all required documents represents a true, accurate and complete disclosure of information.

I consent and agree that any member of the Police Department or Fire Department, as well as other code enforcement or health officers of the City may, at any time, enter and inspect any part of such premises. I shall provide an updated list of all on-site managers to Licensing within ten (10) business days from the date any manager is no longer employed by the licensee or when any new manager is hired by the licensee. I am familiar with the contents of Chapter 4.16 of the City Code pertaining to persons ineligible to obtain the license herein applied for, and understand that the same applies to me and further, I affirmatively state neither I nor any other person having an interest in this business are ineligible to receive a license under its terms.

I hereby authorize disclosure and investigation of my financial records, including those held by third parties, to duly authorized agents of the City of Wichita as necessary to determine qualification for licensure. I also authorize the City of Wichita to send communications to the email address provided on this form. Furthermore, if a Corporation or LLC, I appoint the Process Agent with Power of Attorney , who is a United States citizen and a Kansas resident, upon whom process may be served in any action brought against it.

Furthermore, I hereby agree by signing this oath to comply with all of the laws of the State of Kansas and all rules and regulations prescribed by the City of Wichita and I understand that my liquor license is subject to suspension or revocation by the proper officials for any violation of such law, rules or regulations.