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2. Application Type

   1. New
   2. Renewal
4. COMPLETE ALL 9 SECTIONS, REFER TO K.A.R. 22-26-2 FOR GUIDELINES
6. Section 1 Legal Name
   For background purposes, use full legal name. This name will also be printed on applicant’s permit.
8. Last Name
9. First Name
10. MI
12. Section 2 Applicant's Current Permit Number (if renewal)
14. Permit Number
16. Section 3 Personal Information
18. DOB
    DOB
19. Age
    In years
20. Gender

    1. Male
    2. Female
22. Last 4 digits of Social Security Number
23. Drivers License Number
24. State
26. U.S. Citizen

    1. Yes
    2. No
27. If not a U.S. citizen, please provide Alien Registration Number
29. Have you been convicted of a felony?

    1. Yes
    2. No
31. Section 4 Contact Information
33. Home Phone Number
34. Mobile Number
35. Email Address
37. Section 5 Business Information
39. Business Name
41. Address
43. City
44. State
45. Zip Code
47. Latitude and Longitude of Location
49. Section 6 Physical & Mailing Address
    Physical address of any buildings that are owned/leased by the company and used in any part of the processing operation.
51. Physical
53. Address
55. City
56. County
57. State
58. Zip Code
60. Mailing
    For official correspondence with our office.
62. Address
64. City
65. County
66. State
67. Zip Code
69. Section 7 Officers, Proprietors, Partners of Entity, and Employees
    Each owner of more than a 10% interest in the processing operations, as well as employees.
71. Type

    1. Proprietor

    1. Partner

    1. Officer

    1. Employee
73. Last Name
74. First Name
75. MI
77. DOB
    DOB
78. Age
    In years
79. Gender

    1. Male
    2. Female
81. Last 4 Digits of Social Security Number
82. Driver's License Number
83. State
85. U.S. Citizen

    1. Yes
    2. No
86. If not a U.S. citizen, please provide Alien Registration Number
88. Have you been convicted of a felony?

    1. Yes
    2. No
90. Type

    1. Proprietor

    1. Partner

    1. Officer

    1. Employee
92. Last Name
93. First Name
94. MI
96. DOB
    DOB
97. Age
    In years
98. Gender

    1. Male
    2. Female
100. Last 4 Digits of Social Security Number
101. Driver's License Number
102. State
104. U.S. Citizen

     1. Yes
     2. No
105. If not a U.S. citizen, please provide Alien Registration Number
107. Have you been convicted of a felony?

     1. Yes
     2. No
109. Type

     1. Proprietor

     1. Partner

     1. Officer

     1. Employee
111. Last Name
112. First Name
113. MI
115. DOB
     DOB
116. Age
     In years
117. Gender

     1. Male
     2. Female
119. Last 4 digits of Social Security Number
120. Driver's License Number
121. State
123. U.S. Citizen

     1. Yes
     2. No
124. If not a U.S. citizen, please provide Alien Registration Number
126. Have you been convicted of a felony?

     1. Yes
     2. No
128. If more space is needed for individuals, upload their complete information as supporting documentation below.
130. Section 8 Type of Hemp Processing Method Used

     1. Ethanol
     2. CO2
     3. Cold Press
     4. Agricultural Processor
132. A brief description of the industrial hemp processing methods that will be used, activities that will be undertaken, and finished products planned for production.
134. Section 9 Applicants Signature
136. Under the penalties imposed by K.S.A. 21-3805, I declare that I have examined this application and any documents submitted in support thereof, and to the best of my knowledge and belief, they are true, correct and complete. I also certify that I am familiar with all published state laws and local ordinances relating to hemp processing for the location(s) in which I intend to do business.
138. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
140. Electronic Signature
142. Please upload supporting documents
     Only PDFs are accepted
144. Supporting Documentation
     Additional officers, proprietors, partners of entity and/or employees.
146. Policies and Procedures Manual
148. Fingerprint cards, signed Consent to Search forms and criminal background checks for applicant, additional officers, proprietors, partners of entity and/or employees
150. Code Footprints
152. Supporting documentation can be provided after application is submitted if necessary.
     Supporting documents can be submitted to ksfm_hemp@ks.gov after application is filed.
154. Once your application is approved, you will be notified of any fees that are due.
Leave This Blank:


156. 1. Receive an email copy of this form.
157. Email address

     This field is not part of the form submission.

158. Submit

* indicates a required field