Form Abc-280-9 - Certificate By Licensee Of Members Of The Club printable pdf download

Form Abc-280-9 - Certificate By Licensee Of Members Of The Club

KANSAS DEPARTMENT OF REVENUE

ALCOHOLIC BEVERAGE CONTROL DIVISION

CERTIFICATE BY LICENSEE OF MEMBERS OF THE CLUB

(To Be Filled Out By Class B Private Club Licensees)

, owner or officer of

, an organization applying to be licensed

(name of organization)

as a Class B Private Club under the provisions of K.S.A. 41-2601 et seq. and amendments thereto, hereby certify

that:

1. All members of this organization will have been members for at least 10 days prior to the issuance of the Class B

Private Club license;

2. No future applications for club membership will be granted for at least 10 days subsequent to the receipt of the

application by the club;

3. All present members have been paid and all future members will pay an annual membership fee of at least

$10.00.

Name of Organization

By:

Owner or Officer

STATE OF

)

) ss:

COUNTY OF

)

Be it remembered, that on this ___________day of ____________________________, 20_____, before me, the

undersigned, a Notary Public in and for the county and state aforesaid, came _______________________________,

owner or officer of __________________________________________________________________________, an

organization applying to be licensed as a Class B Private Club under the provisions of K.S.A. 41-2601 et seq. and

amendments thereto, who is personally known to me to be the same person who executed the foregoing instrument

of writing as such owner or officer and duly acknowledge the execution of the same.

Notary Public

ABC-280-9

(Rev. 1/01)

Form Abc-280-9 - Certificate By Licensee Of Members Of The Club