Fillable Form 1.: KANSAS LIQUOR LICENSE OWNERSHIP INSTRUCTIONS (Kansas Department of Revenue)

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Form 1.: KANSAS LIQUOR LICENSE OWNERSHIP INSTRUCTIONS (Kansas Department of Revenue)

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KANSAS LIQUOR LICENSE OWNERSHIP INSTRUCTIONS
GENERAL INSTRUCTIONS
Please complete all information. All questions must be answered fully and truthfully. Additional information may
be found on our website at http://www.ksrevenue.org/abc.html
Do not submit your renewal application to the ABC more than 60 days in advance of the license expiration date.
INSTRUCTIONS TO COMPLETE THE KANSAS LIQUOR LICENSE OWNERSHIP FORM (ABC-890):
Applicants may apply for multiple licenses as permi
tted by law; however, the ownership must be exactly the same for
each of the licenses you are applying for.
NOTE – This form can be saved. We recommend that you save the form prior to entering information and continue to
save information on a regular basis as you enter complete the form.
Section 1 – Entity Corporate Structure:
1.
Enter your entity name and your FEIN.
2
Answer the questions regarding the legal entity.
3.
OWNERSHIP INFORMATION. Complete all required information for each owner or officer and their spouse.
Make sure that you check the box to indicate if the person is or is not the primary contact.
Section 2 – Appointment of Process Agent With Power of Attorney:
1.
Complete the required information for the process agent and their spouse.
Section 3 – Background Qualifications:
1.
Questions apply to all applicants listed in Sections 1 and 2.
Submitting Your Form:
Once you have completed the form, you may digitally sign the form; or, print the form, sign, date the form and save it to
your computer. Upload your completed form to your online application.
If you need assistance, please contact ABC licensing via email to kdor_abc.licensing@ks.gov or by phone
at 785-296-7015.
ABC-890 (11.19.18) Page 1 of 5
ABC-890 (11.19.18) Page 2 of 5
_____________________________________ ___________________ ENTITY NAME: FEIN_
SECTION 1 – ENTITY CORPORATE STRUCTURE
Is the applicant a municipal corporation?
Yes
1
(proceed to Section 2)
1
Requires Management Services Agreement (ABC-807)
No (p
roceed to next question)
Is this a publically traded company?
Yes (complete for corporate officers and spouses; and, anyone with 5% or more
ownership)
No (complete ownership information below for all owners)
*Social Security Number. Under the Federal Privacy Act, disclosure of a social security number in this application is voluntary. If no social
security number is disclosed for each person listed in this application, a state issued driver’s license number or government issued identification
card number must be provided. Any social security number provided may be forwarded to the Department of Social and Rehabilitative Services
in compliance with K.S.A. 39-758.
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. Includes parent company.
President or Equivalent
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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
Vice President or Equivalent
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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
Secretary or Equivalent
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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-890 (11.19.18) Page 3 of 5
ENTITY NAME: FEIN_
Treasurer or Equivalent
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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
Other
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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
Other
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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-890 (11.19.18) Page 4 of 5
ENTITY NAME: FEIN_
Other
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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
Other
Primary Contact:
Yes
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
Marital Status:
Married (complete spousal information)
Single
Email Address
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
SECTION 2 – APPOINTMENT OF PROCESS AGENT WITH POWER OF
ATTORNEY
(Required for Corporations, LLCs and Municipal Corporations)
I am an out-of-state Special Order Shipping license applicant. (Proceed to Section 3).
NOTE: The Process Agent must be a Kansas resident and a United States citizen.
Last Name First Name Middle Name Gender Date of Birth
Social Security Number* Driver’s License No. DL State % Ownership
Address City State
KS
County Zip Code Daytime Phone
Marital Status:
Married (complete spousal information)
Single
Email Address
Process Agent Signature Date Signed Printed Name
Process Agent 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
KS
County Zip Code Daytime Phone
ABC-890 (11.19.18) Page 5 of 5
_____________________________________ ___________________
_______________________________________________________________________________________
________________________________
___________________________
_________ _________________ ________________________
_________ ________________________________ ______________
_______________________________
_________________________________________________________________________
_________________________________________________________________________
ENTITY NAME: FEIN_
SECTION 3 – BACKGROUND QUALIFICATIONS
If the answer to any question is yes, provide explanation on separate page and attach to your application.
1.
Yes No
Has any person listed in Sections 1 and 2 been convicted of a felony in Kansas, in any other state, or under
federal law? If yes, provide the following:
State of conviction: Case #: Name of charge:
_________ _________________ ________________________
2.
Yes No
Has any person
listed in Sections 1 and 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, amphetamines or barbiturates; rape; incest; gambling; adultery; or bigamy) in Kansas or any other
state? If yes, provide the following:
State of conviction: Case #: Name of charge:
3.
Yes No
Has any person listed in Sections 1 and 2 had an alcoholic liquor or cereal malt beverage license revoked in
Kansas or in any state? If yes, provide the following:
State: DBA Name: Date of revocation:
4. Is any person listed in Sections 1 and 2 currently a law enforcement officer or non-elected official who
supervises or appoints any law enforcement officer?
Yes No
5a. Does any person listed in Sections 1 and 2 have an ownership interest in any other business licensed to sell
alcoholic liquor in Kansas? Yes No If yes, provide the following (you may attach a list as required):
DBA Name(s): License Number(s):
5b. Does any person listed in Sections 1 and 2 have an ownership interest in any other business licensed to sell
cereal malt beverage in Kansas? Yes No If yes, provide the following:
License #:
6.
Does any person listed in Sections 1 and 2 not meet the Kansas residency requirement for the type of
license applied for? (Class A & B Club, Caterer or Drinking Establishment – 1 year; Retailer – 4 years;
Manufacturer – 5 years; Farm Winery, Microbrewery or Microdistillery – must be Kansas resident).
Yes No
7.
Is any person
listed in Sections 1 and 2 not a US Citizen? If yes, explain:____________________________
Yes No
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Form 1.: KANSAS LIQUOR LICENSE OWNERSHIP INSTRUCTIONS (Kansas Department of Revenue)

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Completed 8 February 2021

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