Kansas Liquor License Application Instructions - Kansas Alcoholic Beverage Control Page 6
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8Kansas 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 4 – APPOINTMENT OF PROCESS AGENT WITH POWER OF
ATTORNEY - Required for LLC and Corporations
I am applying for a Special Order Shipping license and I have filed my Irrevocable Consent to Jurisdiction with the Kansas Secretary
of State. (Proceed to Section 6).
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
KS
Address
City
State
County
Zip Code
Daytime Phone
KS
Process Agent Spousal Information
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
SECTION 5 – BACKGROUND QUALIFICATIONS
If the answer to any question is yes, provide explanation on separate page and attach to your application.
1. Has any person listed in Sections 3 and 4 been convicted of a felony in Kansas, in any other state, or under
Yes
No
federal law?
2. Has any person listed in Sections 3 and 4 been convicted of a morals charge (prostitution; procuring any
person; solicitation of a child under 18 for immoral act involving sex; possession or sale of narcotics,
Yes
No
marijuana, amphetamines or barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other
state?
3. Has any person listed in Sections 3 and 4 had an alcoholic liquor or cereal malt beverage license revoked in
Yes
No
Kansas or in any state?
4. Is any person listed in Sections 3 and 4 currently a law enforcement officer or non-elected official who
Yes
No
supervises or appoints any law enforcement officer?
5. Does any person listed in Sections 3 and 4 have an ownership interest in any other business licensed to sell
alcoholic liquor or cereal malt beverage in Kansas or any other state? If so, please provide license number.
Yes
No
and state of issue. License Number: ________________________________ State: __________________
6. Does any person listed in Sections 3 and 4 not meet the Kansas residency requirement for the type of
Yes
No
license applied for? (Class A & B Club, Drinking Establishment – 1 year; Farm Winery, Microbrewery or
Retailer – 4 years; Manufacturer – 5 years).
7. Has any person listed in Sections 3 and 4 been a Kansas resident for less than 10 years?
Yes
No
SECTION 6 – BUSINESS ENTITY INFORMATION
I am applying for a Special Order Shipping license and I have filed my Irrevocable Consent to Jurisdiction with the Kansas Secretary
of State. (Proceed to business entity type).
Is your Corporation, Partnership, LLC or LLP in good standing with the Kansas Secretary of State?
Yes*
No
*If yes, attach a letter of good standing (requires fee) or print it from the Secretary of State’s website
(no charge) to the application. To print from the Secretary of State’s website, go to:
N/A
Check one of the following business entity types:
Individual
Is the applicant a resident of Kansas?
Yes
No
I live in ______________________________________ county.
Corporation – Attach a copy of the Articles of Incorporation, By-Laws and Certificate of Authority from the Kansas Secretary of
State’s Office or print out from their website to your application.
Partnership – Attach a copy of the Partnership Agreement to your application.
Partners live in the following county(s):
LLC or LLP – Attach a copy of the Articles of Organization, Operating Agreement and Certificate of Authority from the
Kansas Secretary of State’s Office or print out from their website to your application.
Trust – Attach a copy of the Declaration Of Trust.
Government
Type (check one):
City
County
State
Federal
Other:
ABC-800 (Rev. 8.5.09)
Page 6 of 8
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