Form Abc-282 - Designation Of Agent With Whom The Abc May Discuss Issues In Conjunction With Processing And/or Reviewing Liquor License Application

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DEPARTMENT OF REVENUE
STATE OF KANSAS
ABC/Licensing Segment
Phone: (785) 368-8222
915 SW Harrison St.
FAX: (785) 291-3968
Topeka, KS 66625-2073
Hearing Impaired TTY: (785) 296-6461
Internet Address:
Alcoholic Beverage Control
DESIGNATION OF AGENT WITH WHOM THE ABC MAY DISCUSS ISSUES IN CONJUNCTION WITH
PROCESSING AND/OR REVIEWING LIQUOR LICENSE APPLICATION
INSTRUCTIONS: If you are an individual applying for a liquor license, or if you are part of an entity applying for a liquor
license and you possess authority to designate an agent on the entity’s behalf, you have the option to designate an agent with
whom the ABC may discuss issues in conjunction with processing and/or reviewing the application. Exercising your option to
designate an agent for this purpose can be done only by completing and submitting this form to the ABC, along with your or
the entity’s application materials. The designation made pursuant to this form shall be effective ONLY for the purpose of
processing and/or reviewing the liquor license application. If you wish to also appoint this person as Process Agent with Power
of Attorney, you must do so by executing a separate Ownership Disclosure Form (ABC Form 280-OD). By designating an
agent with whom the ABC may discuss issues in conjunction with processing and/or reviewing your or the entity’s liquor
license application, you and, if applicable, the entity, hereby specifically authorize the ABC to share and discuss with such
agent any and all information contained in or related to the application. Furthermore, you hereby specifically authorize such
agent to answer questions, provide information, and submit documentation for or to the ABC on your and/or the entity’s behalf.
I,
,
(Applicant name)
Individual/President/Partner/Member/Other:
,
(Circle your position/title. If “Other”, fill in the blank)
of
(License applicant’s dba name)
at
,
(Location address of licensee)
(City)
, KS
,
(Zip code)
hereby designate the following to serve as my/the entity’s agent with whom the ABC may discuss issues in conjunction with
processing and/or reviewing the liquor license application:
Name of agent:
Address of agent:
City
State
Zip
Telephone
Fax
E-mail
Signed by
Owner, Officer, Member or Partner
Date
STATE OF KANSAS
)
)
ss.
COUNTY OF ________________________)
SUBSCRIBED AND SWORN TO before me, the undersigned Notary Public in and for the above state and county, on
the ______ day of ___________________, 20_____, upon personal appearance and with proof that he/she is the person named
in and who executed the foregoing instrument as his/her voluntary and knowing act.
(SEAL)
(Notary Public)
My commission expires:
ABC–282 (Rev. 12/04)

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