DEPARTMENT OF REVENUE STATE OF KANSAS ABC/Licensing Segment 915 SW Harrison St. Topeka, KS 66625-2073 Internet Address: www.ksrevenue.org Phone: (785) 368-8222 FAX: (785) 291-3968 Hearing Impaired TTY: (785) 296-6461 Alcoholic Beverage Control DESIGNATION OF AGENT WITH WHOM THE ABC MAY DISCUSS ISSUES IN CONJUNCTION WITH PROCESSING AND/OR REVIEWING LIQUOR LICENSE APPLICATION INSTRUCTIONS: If you are an individual applying for a liquor license, or if you are part of an entity applying for a liquor license and you possess authority to designate an agent on the entity’s behalf, you have the option to designate an agent with whom the ABC may discuss issues in conjunction with processing and/or reviewing the application. Exercising your option to designate an agent for this purpose can be done only by completing and submitting this form to the ABC, along with your or the entity’s application materials. The designation made pursuant to this form shall be effective ONLY for the purpose of processing and/or reviewing the liquor license application. If you wish to also appoint this person as Process Agent with Power of Attorney, you must do so by executing a separate Ownership Disclosure Form (ABC Form 280-OD). By designating an agent with whom the ABC may discuss issues in conjunction with processing and/or reviewing your or the entity’s liquor license application, you and, if applicable, the entity, hereby specifically authorize the ABC to share and discuss with such agent any and all information contained in or related to the application. Furthermore, you 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. I, , (Applicant name) Individual/President/Partner/Member/Other: , (Circle your position/title. If “Other”, fill in the blank) of (License applicant’s dba name) at , (Location address of licensee) (City) , KS , (Zip code) hereby designate the following to serve as my/the entity’s agent with whom the ABC may discuss issues in conjunction with processing and/or reviewing the liquor license application: Name of agent: Address of agent: City State Telephone Fax Zip E-mail Signed by Owner, Officer, Member or Partner Date STATE OF KANSAS ) ) COUNTY OF ________________________) ss. SUBSCRIBED AND SWORN TO before me, the undersigned Notary Public in and for the above state and county, on the ______ day of ___________________, 20_____, upon personal appearance and with proof that he/she is the person named in and who executed the foregoing instrument as his/her voluntary and knowing act. (Notary Public) (SEAL) My commission expires: ABC–282 (Rev. 12/04) American LegalNet, Inc. www.FormsWorkflow.com