Kansas 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 Designation of Agent and/or Process Agent With Power of Attorney Explanation: You have the option to designate an agent with whom the ABC may discuss your license and/or application for liquor licensure. By designating an agent with whom the ABC may discuss your license and/or application, you and, if applicable, the entity, hereby specifically authorize the ABC to share and discuss with such agent any and all information concerning your liquor license, application or any legal proceedings taken by the ABC against your license. You may also appoint the agent or another person as your Process Agent with Power of Attorney. The designation made pursuant to this form shall be effective until the ABC receives a notice withdrawing that appointment. Prerequisite: To appoint an Agent and/or Process Agent with Power of Attorney, you must be: • an individual who holds a liquor license; or, • if you are part of an entity that holds a liquor license, you must have the authority to designate an agent on the entity’s behalf. The Process Agent must be a Kansas resident. INSTRUCTIONS TO COMPLETE THE LIQUOR LICENSE DESIGNATION OF AGENT: 1. Enter your FEIN In the space provided in the upper right corner. 2. Section 1 – Licensee Information a. Enter your license information as required. b. TITLE. Check the applicable box. Section 2 – Designation of Agent a. Read the statement and check the appropriate box. 1. If you checked “Yes”, complete the requested information. 2. If you checked “No”, proceed to Section 3. Section 3 – Appointment of Process Agent with Power of Attorney a. Read the statement and check the appropriate box. 1. If you checked “Yes”, complete the requested information. 2. If you checked “No”, proceed to instruction #3. 3. Read the sworn statement, then the licensee and agent/process agent must sign and date the form. 4. Submit the executed form to the ABC at the address on the form. If you have questions or need assistance, please contact the ABC Licensing Unit by email at abc.licensing@kdor.ks.gov or by phone at 785-296-7015. ABC-808 (Rev. 7.1.11) American LegalNet, Inc. www.FormsWorkFlow.com Kansas 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 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 County Completed By Name: Title: Owner Zip Code Date Officer Member 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 your and/or the entity’s behalf. *If yes, complete the information below. Last Name Address First Name City Yes* No Middle Name State County Zip Code Daytime Phone E-Mail 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. Yes* *If yes, complete the information below. Last Name First Name Middle Name Other Names Used Gender Date of Birth No Birthplace Maiden Name Social Security No. Driver’s License No. State % Ownership Position Marital Status Address City State County Zip Code Daytime Phone Date of Birth Birthplace Process Agent Spousal Information Last Name First Name Middle Name Other Names Used Gender Maiden Name Social Security No. Driver’s License No. 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? 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? 3. Has any person listed in Section 3 had an alcoholic liquor or cereal malt beverage license revoked in Kansas or in any state? 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? 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: __________________ 6. Does any person listed in Section 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 Retailer – 4 years; Manufacturer – 5 years). 7. Has any person listed in Section 3 been a Kansas resident for less than 10 years? Yes No Yes No Yes No Yes No Yes No Yes No 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 e-mail address provided on this form. _______________________________________________ _______________________________________________ Authorized Licensee Signature Agent/Process Agent Signature Date Date ABC-808 (Rev. 7.1.11) American LegalNet, Inc. www.FormsWorkFlow.com Clear Form