Fillable NOTICE OF OFFICER CHANGE (Kansas Department of Revenue)

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NOTICE OF OFFICER CHANGE (Kansas Department of Revenue)

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A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
DEPARTMENT OF REVENUE
P
HONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
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 State County Zip Code
Post or Organization Number E-mail Address
Mailing Address (if different from above) City State County 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 Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
☐
Married (complete spousal information)
☐
Single
☐
☐
E-mail Address
Officer Spousal Information
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential 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 Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
Married (complete spousal information)
Single
E-mail Address
Officer Spousal Information
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
ABC-810 (Rev. 08/19) Page 1 of 3
A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
D
EPARTMENT OF REVENUE
PHONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
FEIN
Secretary or Equivalent
Official Title Replaces
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
☐
Married (complete spousal information)
☐
Single
☐
☐
☐
☐
E-mail Address
Officer Spousal Information
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Treasurer or Equivalent
Official Title Replaces
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
Married (complete spousal information)
Single
E-mail Address
Officer Spousal Information
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Other Officer
Official Title Replaces
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
Married (complete spousal information)
Single
E-mail Address
Officer Spousal Information
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
ABC-810 (Rev. 08/19) Page 2 of 3
A
LCOHOLIC BEVERAGE CONTROL
109 SW 9
th
STREET
P.O. BOX 3506
T
OPEKA KS 66601-3506
D
EPARTMENT OF REVENUE
PHONE: 785-296-7015
F
AX: 785-296-7185
www.ksrevenue.org/abc.html
FEIN
Other Officer
Official Title Replaces
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential Address City State County Zip Code Daytime Phone
Marital Status:
☐
Married (complete spousal information)
☐
Single
E-mail Address
Officer Spousal Information
Last Name First Name Middle Name Gender
Date of Birth Social Security Number Driver’s License Number DL State
Current Residential 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 law?
☐
Yes
☐
No
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, amphetamines or barbiturates; rape; incest;
gambling; adultery; or bigamy) in Kansas or any other state?
☐
Yes
☐
No
3. Has any person listed in Section 2 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 2 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 2 have an ownership interest in any other business licensed to sell alcoholic liquor or cereal malt
beverage in Kansas or any other state? Yes NoIf so,
please provide license number 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 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 not a US Citizen?
Yes No
If yes, exp
lain:
☐
☐
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 Signature Date
ABC-810 (Rev. 08/19) Page 3 of 3
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NOTICE OF OFFICER CHANGE (Kansas Department of Revenue)

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Completed 24 August 2020

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