Form Abc-800 - Kansas Liquor License Application Instructions Page 10
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13Kansas Department of Revenue
Alcoholic Beverage Control Division
915 S.W. Harrison Street, Room 214
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 866-855-5025
FEIN_______________________
SECTION 5 – APPOINTMENT OF PROCESS AGENT WITH POWER OF
ATTORNEY
(Required for LLC, Corporations and Municipal 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 7).
Last Name
First Name
Middle Name
Gender
Date of Birth
Social Security Number*
Driver’s License No.
DL State
% Ownership
Address
City
State
County
Zip Code
Daytime Phone
KS
Married (complete spousal information)
Email Address
Marital Status:
Single
Process Agent Spousal Information
Last Name
First Name
Middle Name
Gender
Date of Birth
Social Security Number*
Driver’s License No.
DL State
% Ownership
Address
City
State
County
Zip Code
Daytime Phone
KS
SECTION 6 – 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 4 and 5 been convicted of a felony in Kansas, in any other state, or under
federal law? If yes, provide the following:
Yes
No
State of conviction:_________ Case #:_________________ Name of charge:________________________
2. Has any person listed in Sections 4 and 5 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,
marijuana, amphetamines or barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other
Yes
No
state? If yes, provide the following:
State of conviction:_________ Case #:_________________ Name of charge:________________________
3. Has any person listed in Sections 4 and 5 had an alcoholic liquor or cereal malt beverage license revoked in
Kansas or in any state? If yes, provide the following:
Yes
No
State:_________ DBA Name:________________________________ Date of revocation:______________
4. Is any person listed in Sections 4 and 5 currently a law enforcement officer or non-elected official who
Yes
No
supervises or appoints any law enforcement officer?
5a. Does any person listed in Sections 4 and 5 have an ownership interest in any other business licensed to sell
alcoholic liquor in Kansas? If yes, provide the following (you may attach a list as required):
Yes
No
DBA Name(s):_______________________________ License Number(s):___________________________
5b. Does any person listed in Sections 4 and 5 have an ownership interest in any other business licensed to sell
cereal malt beverage in Kansas? If yes, provide the following:
Yes
No
License #: ________________________________
6. Does any person listed in Sections 4 and 5 not meet the Kansas residency requirement for the type of
license applied for? (Class A & B Club, Drinking Establishment – 1 year; Farm Winery or Microbrewery – 1
Yes
No
year; Retailer – 4 years; Manufacturer – 5 years).
7a. Is any person listed in Sections 4 and 5 not a US Citizen? If yes, explain:____________________________
Yes
No
_______________________________________________________________________________________
7b. Has any person listed in Sections 4 and 5 not been a US Citizen for at least 10 years? If yes, explain:______
Yes
No
_______________________________________________________________________________________
ABC-800 (Rev. 7.1.12)
Page 10 of 13
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