ALCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P
.
O
. BOX 3506
TOPEKA KS 66601-3506
STATE OF KANSAS
D
EPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
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 State County Zip Code
Completed by Name: Date
Title:
☐
Owner
☐
Officer
☐
M
ember
☐
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 questions, provide
information and submit documentation for or to the ABC on my and/or the entity’s behalf.
*If yes, complete the information below.
☐
Yes*
☐
No
Last Name First Name Middle Name
Address City State County Zip Code
Daytime Phone Email 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. This will apply to all licenses under the entity.
*If yes, complete the information below.
☐ Yes* ☐ No
Last Name First Name Middle Name Gender Date of Birth Birthplace
Other Names Used Maiden Name
Social Security Number Driver’s License Number 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 Number Driver’s License Number 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 barbiturates; rape; incest;
gambling; adultery; or bigamy) in Kansas or any other state?
☐
Yes
☐
No
3. Has any person listed in Section 3 had an alcoholic liquor or cereal malt beverage license revoked in Kansas or in any state?
☐ Yes ☐ No
4. Is any person listed in Section 3 currently a law enforcement officer or non-elected official who supervises or appoints any law
enforcement officer?
☐
Yes
☐
No
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.
License Number:
State:
☐ Yes ☐ No
6. Does any person listed in Sections 2 and 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 Microdistillery – must be Kansas
resident; Retailer – 4 years; Manufacturer – 5 years)
☐
Yes
☐
No
7. Is any person listed in Sections 2 and 3 not a US Citizen? If yes, explain:
☐ 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 email address provided on this form.
Date Agent/Process Agent Signature Date Authorized Licensee
Signature ABC-808 (Rev. 02/19)
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