Fillable Form Abc-805 - Licensee Information And Employee/volunteer Registration printable pdf download

Form Abc-805 - Licensee Information And Employee/volunteer Registration

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Kansas Department of Revenue

Alcoholic Beverage Control Division

915 S.W. Harrison Street, Room 214

Topeka, KS 66625-3512

Phone: 785-296-7015 Fax: 785-296-7185

SECTION 1 – LICENSEE INFORMATION

New Application

Renew Existing License

New Employee/Volunteer

Location DBA Name

License No.

Location Street Address

City

State

Zip

Business Phone No.

E-Mail Address

Contact Person

Additional pages attached. (check one)

Yes Page _____ of _____

(If you have multiple locations, complete a page for each location).

SECTION 2 – EMPLOYEE/VOLUNTEER REGISTRATION

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

Last Name

First Name

Gender

Date of Birth (MM/DD/YYYY)

Male

Female

Government Issued ID No.*

Government Issued ID Type

Issuing Government Agency

Date of Hire (MM/DD/YYYY)

________________________________________

____________________________________

Authorized Signature

Date

________________________________________

____________________________________

Printed Name

Title

*Social Security Number

Under the Federal Privacy Act, disclosure of a social security number in this application is voluntary. If no social security number is disclosed for each

person listed in this application, a state issued driver’s license number or government issued identification card number must be provided. Any social

security number provided may be forwarded to the Department of Social and Rehabilitative Services in compliance with K.S.A. 39-758.

ABC-805 (Rev. 9.27.11)

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