Form Abc-810 - Notice Of Officer Change
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3Kansas 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
NOTICE OF OFFICER CHANGE
All Class A Clubs must complete and submit this form when there are officer changes and no change to the license.
SECTION 1 – LICENSEE INFORMATION
FEIN _____________________
Club Name
License Number
Location Street Address
City
County
Zip Code
Post or Organization #
Email Address
Mailing Address (if different from above)
City
Zip Code
The following information must be provided for all officers
AND the spouses of all submitted
persons. (Attach additional pages as
necessary).
SECTION 2 – NEW OFFICER INFORMATION
President or Equivalent
Official Title
Replaces:
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Officer 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
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Vice President or Equivalent
Official Title
Replaces:
Last Name
First Name
Middle Name
Gender
Date of Birth
Birthplace
Other Names Used
Maiden Name
Social Security No.
Driver’s License No.
State
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
Officer 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
Marital Status
Address
City
State
County
Zip Code
Daytime Phone
ABC-810 (Rev. 7.1.11)
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Parent category: Financial