Form Abc-808 - Designation Of Agent And/or Process Agent With Power Of Attorney Page 2
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2Kansas 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
DESIGNATION OF AGENT AND/OR PROCESS AGENT WITH POWER OF ATTORNEY
SECTION 1 – LICENSEE INFORMATION
FEIN______________________________
Licensee DBA Name
License Number
Location Street Address
City
County
Zip Code
Completed By Name:
Date
Title:
Owner
Officer
Member
Partner
Other:________________________________
SECTION 2 – DESIGNATION OF AGENT
I hereby designate the person below to serve as my/the entity’s agent with whom the ABC may discuss issues
concerning my license and/or application. Furthermore, I/we hereby specifically authorize such agent to answer
Yes*
No
questions, provide information and submit documentation for or to the ABC on your and/or the entity’s behalf.
*If yes, complete the information below.
Last Name
First Name
Middle Name
Address
City
State
County
Zip Code
Daytime Phone
E-Mail Address
SECTION 3 – APPOINTMENT OF PROCESS AGENT WITH POWER OF ATTORNEY
(Must be a Kansas resident).
I hereby designate the person below as Process Agent with Power of Attorney.
Yes*
No
If yes, complete the information below.
*
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Process Agent Spousal Information
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
% Ownership
Position
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Background Qualifications
If the answer to any question is yes, provide explanation on separate page and attach to the form.
1. Has any person listed in Section 3 been convicted of a felony in Kansas, in any other state, or under federal law?
Yes
No
2. Has any person listed in Section 3 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
Yes
No
barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other state?
3. Has any person listed in Section 3 had an alcoholic liquor or cereal malt beverage license revoked in Kansas or in
Yes
No
any state?
4. Is any person listed in Section 3 currently a law enforcement officer or non-elected official who supervises or appoints
Yes
No
any law enforcement officer?
5. Does any person listed in Section 3 have an ownership interest in any other business licensed to sell alcoholic liquor
or cereal malt beverage in Kansas or any other state? If so, please provide license number and state of issue.
Yes
No
License Number: ________________________________ State: __________________
6. Does any person listed in Section 3 not meet the Kansas residency requirement for the type of
license applied for? (Class A & B Club, Drinking Establishment – 1 year; Farm Winery, Microbrewery or
Yes
No
Retailer – 4 years; Manufacturer – 5 years).
7. Has any person listed in Section 3 been a citizen of the United States for less than 10 years?
Yes
No
Under penalties of perjury, I declare the information contained in this document a true, accurate and complete disclosure
of information and I authorize KDOR to send communications to the e-mail address provided on this form.
_______________________________________________
_______________________________________________
Authorized Licensee Signature
Date
Agent/Process Agent Signature
Date
ABC-808 (Rev. 8.14.11)
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