Form Abc-800 - Kansas Liquor License Application Instructions Page 9
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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_______________________
Yes
Other
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
Email Address
Married (complete spousal information)
Marital Status:
Single
Other 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
Other
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
Email Address
Married (complete spousal information)
Marital Status:
Single
Other 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
Other
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
Other 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 9 of 13
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