Form Abc-810 - Notice Of Officer Change Page 3
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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
FEIN_____________________
Other Officer
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
SECTION 3 – 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 2 been convicted of a felony in Kansas, in any other state, or under federal
Yes
No
law?
2. Has any person listed in Section 2 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,
Yes
No
amphetamines or barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other state?
3. Has any person listed in Section 2 had an alcoholic liquor or cereal malt beverage license revoked in Kansas
Yes
No
or in any state?
4. Is any person listed in Section 2 currently a law enforcement officer or non-elected official who supervises or
Yes
No
appoints any law enforcement officer?
5. Does any person listed in Section 2 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.
Yes
No
and state of issue. License Number: ________________________________ State: __________________
6. Does any person listed in Section 2 not meet the Kansas residency requirement for the type of license
Yes
No
applied for?
7. Has any person listed in Section 2 been a Kansas resident for less than 10 years?
Yes
No
SECTION 4 – REQUIRED DOCUMENTATION
I have attached a copy of the meeting minutes reflecting changes in officers and ownership.
Yes
No
Under penalties of perjury, I declare the information contained in this document a true, accurate and
complete disclosure of information.
Licensee/Agent’s Signature
Date
Clear Form
ABC-810 (Rev. 7.1.11)
Page 3 of 3
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Parent category: Financial