Kansas Department of Revenue Alcoholic Beverage Control INSTRUCTIONS FOR EMPLOYEE REGISTRATION FORM, ABC 280 Completion of this information is required pursuant to K.S.A. 41-201, K.S.A. 41-713 and K.S.A. 41-2610. Failure to provide all the required information will result in a delay in processing your license. General Instructions for ALL licensees: 1. Please type or legibly print all of the applicable information requested on this form. 2. At the top of the form, complete the Licensee information: Name of Establishment, License No., Address & Telephone number. a) If this is an application for a new license, check “New” in the upper right-hand corner. b) If this is a renewal application, check “Renewal” in the upper right-hand corner. (See 5 for further instructions.) c) If you are registering new employees/volunteers, check “New persons added….” in the upper right-hand corner. (See 6 for further instructions.) 3. When completing the name, record that information in the order indicated on the form. (Last name, First name, Middle Initial). Please provide the FULL last name AND first name. Signatures of employees/volunteers are NOT acceptable since they are frequently illegible. 4. For each name listed, circle the appropriate Position code, indicate his/her Driver’s License No. or Identification No. including the abbreviation of the State that issued the license, and indicate his/her Date of Birth, Gender and Social Security Number. Forms received with incomplete or illegible information will be returned for proper completion, which will delay the licensee’s application process. 5. For your annual license renewal, provide the names of ALL required employees/volunteers on the Employee Registration form. (See specific requirements below for On-Premise & Off-Premise licensees.) 6. New employees/volunteers in required positions must be registered within 5 days of employment. (See specific requirements below for On-Premise & Off-Premise licensees.) When registering NEW employees/volunteers, do NOT re-submit the names of employees/volunteers previously submitted to ABC in the annual license renewal process. 7. Use an Employee Registration - Continuation sheet (reverse side of ABC 280) as needed to report all required persons. 8. Read the certification statement at the bottom of the form, then sign and date the form before mailing to the address at the bottom of the form. ON-PREMISE LICENSEES -- Drinking Establishments (K.A.R. 14-21-9), Hotels (K.A.R. 14-20-26, 14-21-9 or 14-22-9) , Class A (K.A.R. 14-19-24), Class B Clubs (K.A.R. 14-20-26), Caterers (K.A.R. 14-22-9) & Temporary Permits (K.A.R. 14-23-7) 1. You must register -- list on the Employee Registration form -- employees/volunteers that: a) serve, mix, or dispense liquor, b) ring up sales for liquor, AND c) managers of those positions. Do NOT register cooks, janitors, doorpersons, greeters, security or bussing employees. 2. Servers must be at least 18 years of age. 3. Mixing & dispensing employees must be at least 21 years of age. 4. Since an on-premise licensee cannot employ anyone younger than 18 in the capacity of serving alcohol, no one under 18 years of age should be included on an Employee Registration form. 5. Employees of drinking establishments cannot also be employed as an officer or agent of a liquor manufacturer, distributor or retail liquor store in a position responsible for mixing, serving or dispensing liquor. OFF-PREMISE LICENSEES -- Retail Liquor Stores (K.A.R. 14-13-5) 1. You must register – list on the Employee Registration form – all employees who ring up liquor sales (including owners). 2. All employees must be 21 years of age. 3. Employees of a retail liquor store cannot also be employed by a licensed distributor or be the spouse of an employee of a licensed distributor. ABC 280 Instructions (Rev. 12-04) American LegalNet, Inc. www.FormsWorkflow.com Page _____ of _____ KANSAS DEPARTMENT OF REVENUE Alcoholic Beverage Control EMPLOYEE REGISTRATION PLEASE PRINT OR TYPE See attachment for complete instructions. PLEASE SELECT ONE New Application - List all applicable* persons Renewal Application - List all applicable* persons New persons* added during the licensed year (See all 3 pages.) License No. __ __ - __ __ __ - __ __ __ __ - __ __ Name of Establishment: Location Address: City Zip Code Phone No. ( __ __ __ ) - __ __ __ - __ __ __ __ *ON-PREMISE LICENSEES (Drinking Est., Hotels, Class A/B Clubs, Caterers & Temporary Permit holders) -- List employees/volunteers involved in the mixing, dispensing or serving of alcoholic liquor AND their managers. See instructions for details. *OFF-PREMISE LICENSEES (Retail Liquor Stores) -- List all employees. See instructions for details. POSITION CODES - CIRCLE APPROPRIATE CODE FOR EACH EMPLOYEE: (B) Bartender (W) Waitress/Waiter (C) Clerk (M) Manager PLEASE PRINT: FULL NAME OF EMPLOYEE/VOLUNTEER LAST FIRST POSITION CODE DRIVER'S LIC. # or ID # MI DL or ID STATE DATE OF BIRTH GENDER (See above) B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M Check here SSN # M-F if continued on additional pages. TO THE DIRECTOR OF ABC: I certify that the person(s) whose name appears on this form and any attachments is qualified to be employed in a licensed establishment. I further certify that when a new person is employed, the ABC Director will be notified within 5 days. Dated this _______ day of ____________ ________ ABC 280 Instructions (Rev. 12-04) Send To: Director, Alcoholic Beverage Control Customer Relations/Licensee Segment 915 SW Harrison Topeka, KS 66625-2073 Licensee or Manager Signature American LegalNet, Inc. www.FormsWorkflow.com EMPLOYEE REGISTRATION - Continuation (Please staple multiple sheets of Employee Registrations together.) PLEASE PRINT OR TYPE See attachment for complete instructions. Name of Establishment ______________________________ Page _____ of _____ License No. __ __ - __ __ __ -- __ __ __ __ - __ __ Phone No. ( __ __ __) - __ __ __ - __ __ __ __ POSITION CODES - CIRCLE APPROPRIATE CODE FOR EACH EMPLOYEE: (B) Bartender (W) Waitress/Waiter (C) Clerk (M) Manager POSITION CODE PLEASE PRINT: FULL NAME OF EMPLOYEE/VOLUNTEER LAST FIRST MI DRIVER'S LIC. # or ID # DL or ID STATE DATE OF BIRTH GENDER (See above) B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M M-F B-W-C-M ABC 280 Instructions (Rev. 12-04) SSN # M-F American LegalNet, Inc. www.FormsWorkflow.com