Form Abc-800 - Kansas Liquor License Application Instructions Page 7
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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 4 – BUSINESS OWNERSHIP INFORMATION
Primary contact person with whom the ABC should contact for licensing questions:
(check one):
Owner/Officer (check only one “yes” from officers/owners below)
Process Agent (Section 5)
Authorized Person (Section 12)
Yes (proceed to Section 5)
Is the applicant a municipal corporation?
No (proceed to next question)
Yes (complete for corporate officers and spouses and anyone with 5% or
Is this a publically traded company?
more ownership)
No (complete ownership information below for all owners)
The following information must be provided on the applicant(s); individual owners; partners; all officers and directors (if a corporation
or LLC); and anyone with a financial interest,
AND the spouses of all submitted
persons. (Attach additional pages as necessary). The
percentage(s) of ownership must total 100%. Class A Clubs: officers enter a zero (0) in the % Ownership.
Yes
President or Equivalent
Primary Contact:
No
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
Married (complete spousal information)
Email Address
Marital Status:
Single
Officer 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
Yes
Vice President or Equivalent
Primary Contact:
No
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
Married (complete spousal information)
Email Address
Marital Status:
Single
Officer 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
Yes
Secretary or Equivalent
Primary Contact:
No
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
Married (complete spousal information)
Email Address
Marital Status:
Single
Officer 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
ABC-800 (Rev. 7.1.12)
Page 7 of 13
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