301418
                       KANSAS REGISTRATION SCHEDULE
                  FOR ADDITIONAL BUSINESS LOCATIONS                                                            RCN

                                                                                                                    FOR OFFICE USE ONLY

                                                                               Employer ID Number (EIN): ____________________________
Use this schedule to register a business location in addition to the one listed in PART 4 of form CR-16. Complete this form for each new 
or additional location. You must provide the following information for each new or additional location so that your customer profile can be 
maintained with the most current information. A new Kansas customer identification number is not required for additional locations; report all 
sales for the new or additional location(s) under your current customer identification number.

Check the box for each tax type, license or registration needed for the location listed below.
 Retailers’ Sales Tax                              Tire Excise Tax                         Liquor Drink Tax
 Retailers’ Compensating Use Tax                   Vehicle Rental Excise Tax               Cigarette Vending Machine Permit
 Consumers’ Compensating Use Tax                   Dry Cleaning Surcharge                  Retail Cigarette/Electronic Cigarette License
 Transient Guest Tax                               Liquor Enforcement Tax                  Water Protection/Clean Drinking Water Fee

1. Trade Name of Business: _________________________________________________________________________________________________________
2. Business location (include apartment, suite, or lot number):  ________________________________________________________________________
City:  ________________________________________      County: _________________________________  State: _________   ZIP Code: ___________
3. Is the business located within the city limits:  No     Yes  If yes, what city? ____________________________________________________
4. Describe the primary business activity at this location: ______________________________________________________________________________
Enter business classification NAICS Code (see instructions on page 5): _____________________________________________________________
5. Business Phone: __________________________________       Email: _____________________________________________________________________
6. Date location opened under this ownership:  _________________________
7. Do you ship or deliver merchandise to Kansas customers?        Yes    No
8. Will sales be made from various temporary locations?      Yes      No
9. If your business is seasonal, list the months you operate: ___________________________________________________________________________
10. Is your business engaged in renting or leasing motor vehicles?  Yes  No  Are the leases for more than 28 days?     Yes      No
11. Do you make retail sales of cigarettes and/or electronic cigarettes over-the-counter, by mail, by phone, or over the internet?
 No          Yes  If yes,     enclose with this application, a check or money order for $25 for each location and provide your email or
Web page address: _______________________________________________________________________________________________________________
If you will sell cigarettes over internet, by phone, or via mail order, provide your email or Web page address:  ________________________________
12. Will you be the operator of cigarette vending machines?   No        Yes  If yes, enclose form CG-83 and list the serial number, location
addresses, and manufacturer’s brand name of each machine. Also, enclose a check or money order for $25 for each machine.
13. Is this location a hotel, motel, or bed and breakfast?  No   Yes  If yes, number of sleeping rooms available for rent/lease: _______
14. Do you sell new tires and/or vehicles with new tires?   Yes  No  Estimate your monthly tire tax ($.25 per tire): $ ________________
15. If you are a dry cleaner or laundry retailer, do you have satellite locations or agents in businesses not classified as a dry cleaning or laundry 
facility?    No   Yes  If yes, enclose a listing with name, business type, address, city, state and ZIP code of each satellite location.
16. If you are registering an additional location for Liquor Drink Tax, enter the date of the first sale of alcoholic beverage at this location:
 _____________________________  Check type of license:
   Class “A” Club               Class “B” Club                         Caterer                               Hotel (entire premises)
   Hotel/Caterer                Drinking Establishment                 Drinking Establishment/Caterer        Producer
17. Are you a public water supplier making retail sales of water delivered through mains, lines, or pipes?     Yes  No
18. Do you make retail sales of motor vehicle fuels or special fuels?  No   Yes  If yes, you must have a Kansas Motor Fuel Retailers’
License. The application (MF-53) is available on our website or office. Complete a separate application for each retail location.
 _________________________________________________________________________________________________________________________________________

      Send this form and any payments to: Kansas Department of Revenue, PO Box 3506, Topeka KS 66625-3506
                                 or FAX to 785-291-3614. For assistance call 785-368-8222.
CR-17 (Rev. 6-20)
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