Abc-280 -Ownership Disclosure Form

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KANSAS DEPARTMENT OF REVENUE
ALCOHOLIC BEVERAGE CONTROL DIVISION
OWNERSHIP DISCLOSURE FORM
REVIEW ATTACHED INSTRUCTIONS FOR FURTHER CLARIFICATION
INCOMPLETE APPLICATIONS WILL BE RETURNED
SECTION 1
TYPE OF BUSINESS __ Individual __ Corporation __ Partnership/Ltd. Part. __ Ltd. Liab.Co.
TYPE OF LICENSE __ Class A __ Class B __ Drinking Establishment (DE) __ Caterer __ Hotel
__ DE/Caterer __ Hotel/Caterer __ Retail Store __ Distributor* __ Farm Winery/Outlet __ Micro-Brewery
*Beer/Wine/Spirits (Circle appropriate one)
NAME OF BUSINESS
__________________________________________________________________________
Doing Business As (DBA)
Corporation Name (if applicable)
ADDRESS OF BUSINESS
__________________________________________________________________________
Street
City
County
Zip
LICENSE NUMBER
FED. EMPL. I.D. NO. (FEIN)
_______________________________
_____________________
(Renewal Applications Only)
REQUIRED
SECTION 2 INFORMATION ON APPLICANT(S) & THEIR SPOUSE(S) –
LAST NAME
FIRST NAME
MIDDLE
*RACE
SEX
DATE OF BIRTH
BIRTHPLACE
OTHER NAMES USED
MAIDEN NAME
SOCIAL SECURITY #
DRIVERS LICENSE #
STATE
(%) OWNERSHIP
POSITION
MARITAL STATUS
HOME ADDRESS
CITY
COUNTY
STATE
ZIP CODE
DAYTIME PHONE
LAST NAME
FIRST NAME
MIDDLE
*RACE
SEX
DATE OF BIRTH
BIRTHPLACE
OTHER NAMES USED
MAIDEN NAME
SOCIAL SECURITY #
DRIVERS LICENSE #
STATE
(%) OWNERSHIP
POSITION
MARITAL STATUS
HOME ADDRESS
CITY
COUNTY
STATE
ZIP CODE
DAYTIME PHONE
LAST NAME
FIRST NAME
MIDDLE
*RACE
SEX
DATE OF BIRTH
BIRTHPLACE
OTHER NAMES USED
MAIDEN NAME
SOCIAL SECURITY #
DRIVERS LICENSE #
STATE
(%) OWNERSHIP
POSITION
MARITAL STATUS
HOME ADDRESS
CITY
COUNTY
STATE
ZIP CODE
DAYTIME PHONE
LAST NAME
FIRST NAME
MIDDLE
*RACE
SEX
DATE OF BIRTH
BIRTHPLACE
OTHER NAMES USED
MAIDEN NAME
SOCIAL SECURITY #
DRIVERS LICENSE #
STATE
(%) OWNERSHIP
POSITION
MARITAL STATUS
HOME ADDRESS
CITY
COUNTY
STATE
ZIP CODE
DAYTIME PHONE
PAGE 1 OF 2
ABC-280-OD

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