Kansas Liquor License Application Instructions - Kansas Alcoholic Beverage Control Page 8
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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
SECTION 11 – DESIGNATION OF AGENT WITH WHOM ABC MAY DISCUSS
MY LICENSE AND/OR APPLICATION
Check one:
I designate the following person.
I do not wish to designate a person.
Agent Name
Daytime Phone
Address
City
State
Zip Code
E-Mail Address
SECTION 12 – PRIMARY CONTACT PERSON FROM SECTION 3 TO WHOM
ABC WILL DIRECT INQUIRIES
(Complete if different from Process Agent).
Last Name
First Name
Middle Name
Position
Daytime Phone
E-Mail Address
SECTION 13 – Application Oath
Under penalties of perjury, I declare the information contained in this document and all application materials represents a true, accurate
and complete disclosure of information.
I hereby authorize disclosure and investigation of my financial records, including those held by third parties, to duly authorized agents of
the Director of Alcoholic Beverage Control as necessary to determine qualification for licensure. I also authorize KDOR to send
communications to the e-mail address provided on this form. Furthermore, if a Corporation or LLC, I appoint the Process Agent with
Power of Attorney identified in Section 4, who is a United States citizen and a Kansas resident, upon whom process may be served in
any action brought against it
__________________________________________________________________________________________________________________
Signature of Applicant
Date
Clear Form
ABC OFFICE USE ONLY:
Correct license and registration fees paid.
30 Day Start Date: _____________________ Associate Initials: _________________
Correspondence Sent Date: __________________ Completed Date: ____________________ Associate Initials: _________________
QA Check
Date: __________________ Associate Initials: __________________
ABC-800 (Rev. 8.5.09)
Page 8 of 8
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