Kansas Liquor License Application Instructions - Kansas Alcoholic Beverage Control Page 5

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Kansas Alcoholic Beverage Control
Licensing Unit
915 SW Harrison Street, Room 214
Topeka, KS 66625-3512
Telephone 785-296-7015
FAX 785-296-7185
FEIN_______________________
SECTION 3 – BUSINESS OWNERSHIP INFORMATION
The following information must be provided on the applicant(s); individual owners; partners; all officers and directors (if a corporation
or LLC); and anyone with a financial interest,
AND the spouses of all submitted
persons. (Attach additional pages as necessary). The
percentage(s) of ownership must total 100%.
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
ABC-800 (Rev. 8.5.09)
Page 5 of 8

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