Our fees increased September 1, 2003. Please review
the instruction box on the form for the new fee.
Contact Information KANSAS SECRETARY OF STATE
Kansas Secretary of State Bonded Warehouse License Application BW
Memorial Hall, 1st Floor 55
120 S.W. 10th Avenue All information must be completed or this document will not be accepted for filing.
Topeka, KS 66612-1594
www.kssos.org Print Reset
1. Name of the applicant: __________________________________
Please complete the form, print, sign and
_______________________________________________________ mail to the Kansas Secretary of State with
Street address the filing fee. Selecting 'Print' will print
the form and 'Reset' will clear the entire
___________________________ _____________ ____________
City State Zip form.
(The applicant’s name must be identical on both the application and the bond.) Do not write in this space
2. If the applicant is a corporation, list the names and addresses of the officers and directors below. If the applicant is a partnership, list
the names and addresses of the partners below.
Name Title Street address City State Zip
3. Place(s) of business where the applicant will operate as a bonded warehouse.
Street address City State Zip
Maximum value of property by the applicant stored at any time during the period for which this application is effective, not including
property owned by the applicant, $ _________________ .
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct.
Executed on the _________ of _____________ , __________ .
Day Month Year
1. Submit this form with bond and the $40 filing fee.
2. All licenses expire on December 31 of each year. A new application and bond must be submitted annually.
Notice: There is a $25 service fee for all returned checks.
Rev. 8/11/03 amc K.S.A. 82-163