Form Abc-800 - Kansas Liquor License Application Instructions (Page 13 of 13) in pdf

Form Abc-800 - Kansas Liquor License Application Instructions Page 13

Kansas 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 12 – AUTHORIZED PERSON TO DISCUSS MY LICENSE AND/OR

APPLICATION WITH ABC

Check one:

I designate the following person.

I designate the following person/agent as my primary contact. (Check this box only if indicated in Section 4).

I do not wish to designate a person.

Name

Daytime Phone

Address

City

State

Zip Code

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 5, 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

__________________________________________________________________________________________________________________

Printed Name

Title

Clear Form

ABC-800 (Rev. 7.1.12)

Page 13 of 13

Form Abc-800 - Kansas Liquor License Application Instructions Page 13