Start Date* Required Required

Date of Birth* Required

Business Entity Name * 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

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*

Resident Agent Information

Name (First Middle Last)* Required
Address* Required Required
City* Required State* Enter a Valid US State Required Required Zip* Required Minimum 5 characters required. Required
Primary Phone* Required Email* Please enter a valid e-mail address. Required

Property Owner Information

Name (Person or Business)* Required
Address* Required Required
City* Required State* Enter a Valid US State Required Required Zip* Required Minimum 5 characters required. Required
Primary Phone* Required Email* Please enter a valid e-mail address. Required

Lessee Information

Name (Person or Business)* Required
Address* Required Required
City* Required State* Enter a Valid US State Required Required Zip* Required Minimum 5 characters required. Required
Primary Phone* Required Lease Length* Required Required

Name* Required
Address* Required
City* Required State* Required Zip* Required
Primary Phone* Required Minimum 10 digit phone required.
Last 4 of SSN* Required Enter 4 digits
Date of Birth* Required

Name Required
Address Required
City Required State Required Zip Required
Primary Phone Required Minimum 10 digit phone required.
Last 4 of SSN Required Enter 4 digits
Date of Birth Required

Name Required
Address Required
City Required State Required Zip Required
Primary Phone Required Minimum 10 digit phone required.
Last 4 of SSN Required Enter 4 digits
Date of Birth Required

Name Required
Address Required
City Required State Required Zip Required
Primary Phone Required Minimum 10 digit phone required.
Last 4 of SSN Required Enter 4 digits
Date of Birth Required

State the reason therefor and the business activity or occupation of the individual subsequent to such suspension, revocation or denial: Required Required

Upload additional information (if necessary) Required

Upload additional information (if necessary) Required

7. Detailed plans and drawing of the establishment and adjoining areas indicating the entertainment space, the waiting area for persons seeking admission, the parking areas, all restrooms, coat rooms, game rooms and all other spaces accessible by patrons and all interior and exterior doors and windows, and all sources of exterior lighting * Required

Upload additional information (if necessary) Required

Upload additional information (if necessary) Required

Upload additional information (if necessary) Required

Upload additional information (if necessary) Required

Upload additional information (if necessary) Required

Upload additional information (if necessary) Required

16. Will cereal malt beverages or alcoholic liquor be sold to patrons* Yes No Required Required

17. The establishment’s written procedures for insuring that only persons twenty one (21) years or older are served alcohol; * Required Required

The above named applicant for an entertainment establishment license, has read the contents of this application and hereby affirms and attests that all the information it contains is true and correct.

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 am familiar with the contents of Chapter 3.30 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.

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

I hereby certify that I have not within the last 10 years, been convicted of or placed on diversion for a felony.

I hereby certify that within the last 3 years, I have not been convicted of or placed on diversion for a misdemeanor involving:

1. Laws pertaining to any controlled substance(s) prohibited by the Uniform Controlled Substance Act, K.S.A. 65-4101 et seq. and amendments thereto;
2. Laws pertaining to alcohol or cereal malt beverage;
3. Prostitution;
4. Public indecency;
5. A sex crime or other person crime as defined by Chapter 21 of the Kansas Statutes Annotated;
6. Any crime of violence or physical force;
7. Any weapons charge; or
8. Violations of this chapter, or Sections 3.08.030 or Chapter 3.28 of the Code of the City of Wichita.