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 KANSAS LIQUOR LICENSE APPLICATION INSTRUCTIONS GENERAL INSTRUCTIONS Please complete all information. All questions must be answered fully and truthfully. You must submit your application with original signatures. Completed applications are submitted to the Alcoholic Beverage Control at the address on the form. Application begins on page 4. Additional information may be found on our website at http://www.ksrevenue.org/abc.html APPLICATION PREREQUISITES 1. You are required to obtain a Federal Employer Identification Number (FEIN) prior to submitting your application for liquor licensure. 2. You must obtain your standard Tax Clearance Certificate prior to completing your application for liquor licensure. Additional information is available on the Kansas Department of Revenue’s website. View this information and request your tax clearance at: http://www.ksrevenue.org/taxclearance.html ADDITIONAL STATE TAXATION REQUIREMENTS – BUSINESS TAX REGISTRATION Your business must be registered with the Kansas Department of Revenue to collect and pay all applicable taxes, including liquor drink, liquor enforcement, sales tax, withholding, etc. If you are required to collect Liquor Drink tax, you must also post a Liquor Drink tax bond with the Director of Taxation. To register, complete the KS-1216 Business Tax Application booklet and submit with your liquor license application or you may register online at https://www.accesskansas.org/businesscenter/index.html INSTRUCTIONS TO COMPLETE THE APPLICATION FOR LIQUOR LICENSE (ABC-800): Applicants may apply for multiple licenses as permitted by law; however, the ownership must be exactly the same for each of the licenses you are applying for. Section 1 – Business Entity Information: 1. APPLICATION TYPE: a. If you are applying for a new license(s), check the “New License” box, then check the appropriate box to indicate the method selected for your business tax registration. b. If you are renewing your license(s), check the “Renew License(s)” box and enter your expiration date. If you have multiple licenses, enter the earliest license expiration date. 2. BUSINESS MAILING ADDRESS FOR ALL LICENSES. Enter the required mailing and contact information. Section 2 – BUSINESS LOCATION INFORMATION 1. Check the appropriate box, new or renewal and enter the license type. If you are renewing your license, enter your license number for the location. 2. Complete the required information. Attach additional pages for multiple locations as necessary. Section 3 – License Types and Fees 1. LICENSE TYPE. Check the appropriate box for the type of license for which you are applying. If you are applying for multiple licenses, check each license type. 2. QUANTITY. Enter the number of licenses you are applying for in both quantity columns. 3. REGISTRATION FEE. Check the appropriate box for either a new or renewal application. 4. TOTAL. Multiply the quantity times the license fee; multiply the quantity times the registration fee, then add the two amounts together and enter that amount in the TOTAL column. 5. TOTAL FEES DUE. Add the amounts in the Total column, then enter the total amount into the TOTAL FEES DUE box. 6. PAYMENT OPTION. Check one. Section 4 – Business Ownership Information* This information is required for individual owners; partners; all officers and directors of a corporation or LLC; and, anyone with a financial interest, including spouses. The ownership must total 100%. Class A Clubs: officers enter a zero (0) in the % Ownership. 1. Answer the ownership questions. 2. Complete the required information for each person with a financial interest in the business. 3. Attach additional pages as necessary and submit with your application. NOTE: If you are applying for a Special Order Shipping license and are not located in Kansas, you are not required to complete this section. *See Social Security Number Disclosure statement on page 4. ABC-800 (Rev. 7.1.12) Page 1 of 13 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 Section 5 – Appointment of Process Agent with Power of Attorney* The Process Agent is required for LLCs, Corporations and Municipal Corporations. They must be a Kansas resident and they are required to provide spousal information if they are married. 1. Enter all required information for your Process Agent. a. Check the box, “I am applying for a Special Order Shipping license and I have filed my Irrevocable Consent to Jurisdiction with the Kansas Secretary of State. (Proceed to the next Section). b. If you were required to file the Irrevocable Consent to Jurisdiction, attach a copy of this form that has been stamped “FILED” by the Kansas Secretary of State’s office and submit with your new application for liquor license. Not required to attach for renewal applications. NOTE: If you are an out-of-state winery applying for a Special Order Shipping license, you must appoint the Kansas Secretary of State as your process agent by filing the Irrevocable Consent to Jurisdiction form (ABC-160) with their office. *See Social Security Number Disclosure statement on page 4. Section 6 – Background Qualifications Applicants, owners and process agents must meet certain qualifications required by the Liquor Control Act and the Club and Drinking Establishment Act. 1. Check the appropriate box to answer each question truthfully for all applicants you have listed in Sections 4 and 5. 2. If the answer to any question is yes, you must provide an explanation on a separate page and attach to your application. Section 7 – Business Entity Information 1. GOOD STANDING. Your corporation, partnership, LLC or LLP must be in good standing with the Kansas Secretary of State. You are required to attach a certificate of good standing which may be obtained from the Secretary of State’s office for a fee; or, you may submit a business entity search results print from the Secretary of State’s website at no charge. Go to: http://www.accesskansas.org/srv-corporations/compressed.do If you do not have a corporation, partnership LLC or LLP, check the N/A box. NOTE: If you are an out-of-state winery applying for a Special Order Shipping license, check the box, “I have filed my Irrevocable Consent to Jurisdiction” and proceed to the business entity type section. 2. BUSINESS ENTITY TYPE. Check the box for your entity type and attach the required documentation to your application as listed by your entity type. NOTE: Corporations must be a Kansas corporation unless you are a an out-of-state winery applying for a Special Order Shipping license, which requires filing the Irrevocable Consent to Jurisdiction (ABC-160). If you are an out-of-state winery applying for a Special Order Shipping license, you are not required to submit documents. Section 8 – Tax Clearance All taxes due to the State of Kansas must be filed and paid prior to obtaining a liquor license. 1. Check the appropriate box to answer the question. a. If you answered “Yes”, enter the confirmation number on your Tax Clearance certificate. b. If you answered “No”, refer to the Application Prerequisite section on page 1 for information to obtain your Tax Clearance certificate. Section 9 – Premise(s) Information Applicants must provide information regarding ownership of the proposed location. If you lease the premise, the lease must be valid at the time of application. 1. Check the appropriate box for each question. If you answered “Yes” to any question, attach any required information to your application. 2. If you have multiple locations, check the box “List attached for multiple locations” and attach the list to your application. NOTE: If you are an out-of-state winery applying for a Special Order Shipping license, you are not required to submit documents. Section 10 – Management Services Disclosure Performance of management or operational services means the exercise of control by any person(s) or entity other than the owner(s) or partners of a licensee on behalf of the licensee or its owner(s) or partners over the hiring, firing and/or supervising of employees; ordering, inventory placement and coordinating order delivery to the store; advertising, marketing or promotional programs enlisted, offered or utilized by the store; negotiating, entering into and/or execution of contracts to which the store is a party; payment or authorization to pay for services provided to or purchases made by the store; and performance of any other similar task(s) central to the operation or ability to operate the store. 1. Check the box to answer the question regarding use of management or operational services. a. If you answered “Yes”, you must complete and attach the Management Services Information form (ABC807). NOTE: Required for municipal corporations. ABC-800 (Rev. 7.1.12) Page 2 of 13 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 Section 11 – Determination of Food Sales Requirement Applies to applicants who are also licensed food service establishments and are located in a county that requires 30% of gross sales to be from food sales and to Class B Clubs who have reciprocal agreements and/or multiple ownership. Section 12 – Authorized Person You have the option to designate an authorized person or agent with whom the ABC may discuss your license and/or application for liquor licensure. You may also designate this person as your primary contact person. 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 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 your appointment. 1. Check one box. Section 13 – Application Oath Read the application oath, then sign the application, enter the date signed, print your name and your title. Finalizing Your Application: Attach all required documentation to your application and the appropriate license fee(s) and registration fee(s) for each license. You have the following payment options: a. pay the license fee and registration fee in full; or, b. pay ½ the license fee and the entire registration fee1. The remaining ½ of the license fee plus a 10% surcharge must be paid within one year or your license will automatically be cancelled. (Refer to Section 3). c. make your check or money order payable to the “Kansas Department of Revenue”. Submit your application and payment to the address on the form. Contact Information: Questions may be directed to the ABC Licensing Unit. Email: abc.licensing@kdor.ks.gov Phone: 785-296-7015, press option #2 ABC-800 (Rev. 7.1.12) Page 3 of 13 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 KANSAS LIQUOR LICENSE APPLICATION SECTION 1 – BUSINESS ENTITY INFORMATION Check one application type: NEW LICENSE (check one): I have completed my Business Tax Application (KS-1216) and will submit with my liquor license application. I have registered for my business taxes online. https://www.accesskansas.org/businesscenter/index.html RENEW LICENSE(S) EXPIRATION DATE: Business Mailing Address for All Licenses FEIN: Business Entity Name Contact Person Name Business Mailing Address City State Business Phone No. Zip E-Mail Address *Social Security Number Under the Federal Privacy Act, disclosure of a social security number in this application is voluntary. If no social security number is disclosed for each person listed in this application, a state issued driver’s license number or government issued identification card number must be provided. Any social security number provided may be forwarded to the Department of Social and Rehabilitative Services in compliance with K.S.A. 39-758. ABC OFFICE USE ONLY: License Fee Registration Fee Associate Initials/Date Full Amount $____________________ $50 New License $10 Renew License st Amount $____________________ $50 New License $10 Renew License 1 Half ALCOHOLIC BEVERAGE CONTROL DIVISION LICENSE FEE VOUCHER DBA Name: TOTAL AMOUNT License Number(s): Full License Fee: $ 1st Half License Fee: $ ABC-800 (Rev. 7.1.12) CLFE CLPR CLFE CLPR Registration Fee: (CLPR) Registration Fee: (CLPR) $50 New License $10 Renewal $50 New License $10 Renewal $ $ Page 4 of 13 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 FEIN_______________________ SECTION 2 – BUSINESS LOCATION INFORMATION Location Information Check One: New License License Type: _____________________________________ Renew License No. _____________________________________________ Location DBA Name Location Street Address City County Business Phone No. E-Mail Address Location Information Check One: State New License Zip License Type: _____________________________________ Renew License No. _____________________________________________ Location DBA Name Location Street Address City County Business Phone No. E-Mail Address Location Information Check One: State New License Zip License Type: _____________________________________ Renew License No. _____________________________________________ Location DBA Name Location Street Address City County Business Phone No. E-Mail Address Location Information Check One: State New License Zip License Type: _____________________________________ Renew License No. _____________________________________________ Location DBA Name Location Street Address City County Business Phone No. E-Mail Address Location Information Check One: State New License Zip License Type: _____________________________________ Renew License No. _____________________________________________ Location DBA Name Location Street Address City County Business Phone No. E-Mail Address Location Information Check One: State New License Zip License Type: _____________________________________ Renew License No. _____________________________________________ Location DBA Name Location Street Address City County Business Phone No. E-Mail Address ABC-800 (Rev. 7.1.12) State Zip Page 5 of 13 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 SECTION 3 – LICENSE TYPES and FEES License Type QTY Class A Club (Fraternal/Veterans) Class A Club – Social (500 members or less) Class A Club – Social (Over 500 members) Class B Club Caterer DE/Caterer Drinking Establishment (DE) Hotel Hotel/Caterer Public Venue – up to 10,000 persons Public Venue – up to 25,000 persons Public Venue – more than 25,000 persons x x x x x x x x x x x x x Two Year License Fee $ 500 $1,000 $2,000 $2,000 $ 1,000 $3,000 $2,000 $6,000 $7,000 $5,000 $7,500 $10,000 $ 500 Retailer $ 100 Microbrewery x x x Microbrewery Packaging and Warehousing Facility x $ 200 Microdistillery x $ 500 Microdistillery Packaging and Warehousing Facility x $ 200 Manufacturer – Alcohol & Spirits x x $5,000 x x x x x x x x x x x $2,000 x x x x x x $ Farm Winery Farm Winery Outlet Manufacturer – Wine $ 500 $ 500 $1,000 + QTY x + + + + + + + + + + + + + + + + + + + + + x x x x x x x x x x x x Registration Fee Add Fee for each License New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 x x x x New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 x x New $50 Renew $10 New $50 Renew $10 x x New $50 Renew $10 New $50 Renew $10 + + + + + + + + + + + x x x x x x x x x x x New $50 + + + + + + x x x x x x = Total = = = = = = = = = = = = = = = = = = = = = $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ = = = = = = = = = = = $ $ $ $ $ $ $ $ $ $ $ = = = = = = $ $ $ $ $ $ $ $ $ $ $ Manufacturer – Beer and CMB First Year 1-100 Barrels 100-150 Barrels 150-200 Barrels 200-300 Barrels 300-400 Barrels 400-500 Barrels 500 or more Barrels Wine Distributor Beer Distributor Spirits Distributor $ 400 $ 800 $1,400 $2,000 $2,600 $2,800 $3,200 $2,000 $2,000 $2,000 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 New $50 Renew $10 Non-Beverage User (Fee Based on Usage) Class 1 – up to 100 Gallons Class 2 – up to 1,000 Gallons Class 3 – up to 5,000 Gallons Class 4 – up to 10,000 Gallons Class 5 – over 10,000 Gallons Special Order Shipping 20 $ 100 $ 200 $ 400 $1,000 $ 100 Payment Option: (check one): License fee and registration fee in full. st 1 1 half license fee plus the entire registration fee . 1 TOTAL FEES DUE $ If you select this option, you must submit the 2nd half license fee plus a 10% surcharge within one year or your license will be automatically cancelled. ABC-800 (Rev. 7.1.12) Page 6 of 13 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 FEIN_______________________ SECTION 4 – BUSINESS OWNERSHIP INFORMATION Primary contact person with whom the ABC should contact for licensing questions: (check one): Owner/Officer (check only one “yes” from officers/owners below) Process Agent (Section 5) Authorized Person (Section 12) Yes (proceed to Section 5) Is the applicant a municipal corporation? No (proceed to next question) Yes (complete for corporate officers and spouses and anyone with 5% or more ownership) Is this a publically traded company? No (complete ownership information below for all owners) The following information must be provided on the applicant(s); individual owners; partners; all officers and directors (if a corporation or LLC); and anyone with a financial interest, AND the spouses of all submitted persons. (Attach additional pages as necessary). The percentage(s) of ownership must total 100%. Class A Clubs: officers enter a zero (0) in the % Ownership. President or Equivalent Primary Contact: Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name Marital Status: DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Officer Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Vice President or Equivalent Primary Contact: Last Name First Name Social Security Number* Address City Middle Name Driver’s License No. Marital Status: Daytime Phone DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Officer Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Secretary or Equivalent Primary Contact: Last Name First Name Social Security Number* Address City Middle Name Driver’s License No. Marital Status: Daytime Phone DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Officer Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name ABC-800 (Rev. 7.1.12) DL State State County % Ownership Zip Code Daytime Phone Page 7 of 13 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 FEIN_______________________ Treasurer or Equivalent Primary Contact: Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name Marital Status: DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Officer Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Other Primary Contact: Last Name First Name Social Security Number* Address City Middle Name Driver’s License No. Marital Status: Daytime Phone DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Other Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Other Primary Contact: Last Name First Name Social Security Number* Address City Middle Name Driver’s License No. Marital Status: Daytime Phone DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Other Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name ABC-800 (Rev. 7.1.12) DL State State County % Ownership Zip Code Daytime Phone Page 8 of 13 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 FEIN_______________________ Other Primary Contact: Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name Marital Status: DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Other Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Other Primary Contact: Last Name First Name Social Security Number* Address City Middle Name Driver’s License No. Marital Status: Daytime Phone DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Other Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Other Primary Contact: Last Name First Name Social Security Number* Address City Middle Name Driver’s License No. Marital Status: Daytime Phone DL State State Married (complete spousal information) Single Gender County Yes No Date of Birth % Ownership Zip Code Daytime Phone Gender Date of Birth Email Address Other Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name ABC-800 (Rev. 7.1.12) DL State State County % Ownership Zip Code Daytime Phone Page 9 of 13 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 FEIN_______________________ SECTION 5 – APPOINTMENT OF PROCESS AGENT WITH POWER OF ATTORNEY (Required for LLC, Corporations and Municipal Corporations) I am applying for a Special Order Shipping license and I have filed my Irrevocable Consent to Jurisdiction with the Kansas Secretary of State. (Proceed to Section 7). Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name Gender Date of Birth DL State State County % Ownership Zip Code Daytime Phone Gender Date of Birth KS Marital Status: Married (complete spousal information) Single Email Address Process Agent Spousal Information Last Name First Name Social Security Number* Driver’s License No. Address City Middle Name DL State State County % Ownership Zip Code Daytime Phone KS SECTION 6 – BACKGROUND QUALIFICATIONS If the answer to any question is yes, provide explanation on separate page and attach to your application. 1. Has any person listed in Sections 4 and 5 been convicted of a felony in Kansas, in any other state, or under federal law? If yes, provide the following: State of conviction:_________ Case #:_________________ Name of charge:________________________ Yes No 2. Has any person listed in Sections 4 and 5 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? If yes, provide the following: State of conviction:_________ Case #:_________________ Name of charge:________________________ Yes No 3. Has any person listed in Sections 4 and 5 had an alcoholic liquor or cereal malt beverage license revoked in Kansas or in any state? If yes, provide the following: State:_________ DBA Name:________________________________ Date of revocation:______________ Yes No Yes No Yes No Yes No Yes No Yes No Yes No 4. Is any person listed in Sections 4 and 5 currently a law enforcement officer or non-elected official who supervises or appoints any law enforcement officer? 5a. Does any person listed in Sections 4 and 5 have an ownership interest in any other business licensed to sell alcoholic liquor in Kansas? If yes, provide the following (you may attach a list as required): DBA Name(s):_______________________________ License Number(s):___________________________ 5b. Does any person listed in Sections 4 and 5 have an ownership interest in any other business licensed to sell cereal malt beverage in Kansas? If yes, provide the following: License #: ________________________________ 6. Does any person listed in Sections 4 and 5 not meet the Kansas residency requirement for the type of license applied for? (Class A & B Club, Drinking Establishment – 1 year; Farm Winery or Microbrewery – 1 year; Retailer – 4 years; Manufacturer – 5 years). 7a. Is any person listed in Sections 4 and 5 not a US Citizen? If yes, explain:____________________________ _______________________________________________________________________________________ 7b. Has any person listed in Sections 4 and 5 not been a US Citizen for at least 10 years? If yes, explain:______ _______________________________________________________________________________________ ABC-800 (Rev. 7.1.12) Page 10 of 13 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 FEIN_______________________ SECTION 7 – BUSINESS ENTITY INFORMATION I am applying for a Special Order Shipping license and I have filed my Irrevocable Consent to Jurisdiction with the Kansas Secretary of State. (Proceed to business entity type). Is your Corporation, Partnership, LLC or LLP in good standing with the Kansas Secretary of State? Yes* No *If yes, attach a Certificate of Good Standing (requires fee) or search results print out from the Secretary of State’s website (no charge) to the application. To print from the Secretary of State’s N/A website, go to: http://www.accesskansas.org/srv-corporations/compressed.do Check one of the following business entity types: Individual Is the applicant a resident of Kansas? Yes No I live in ______________________________________ county. Corporation – Attach a copy of the Articles of Incorporation and By-Laws to your application. (New applicants only). General Partnership – Attach a copy of the Partnership Agreement to your application. (New applicants only). Partners live in the following county(ies): LLC or LLP – Attach a copy of the Articles of Organization and Operating Agreement. (New applicants only). Trust – Attach a copy of the Declaration Of Trust. Municipal Corporation – (Requires Process Agent and Management Services Agreement). Government – (check one): City County State Federal Other: SECTION 8 – TAX CLEARANCE Has the applicant obtained their Tax Clearance certificate? *If yes, enter your Tax Clearance confirmation number:_______________________________________ **If no, you must request your Tax Clearance certificate. To obtain your tax clearance, go to: http://www.ksrevenue.org/taxclearance.html after saving this document Yes* No** Yes* No Yes* No Yes* No Yes* No Yes* No SECTION 9 – PREMISE(S) INFORMATION List attached for multiple locations Does the applicant own the proposed location? *If yes, attach a copy of the Deed to the application. (New applicants only). Does the applicant have a purchase agreement for the proposed location? *If yes, attach a copy of the Purchase Agreement to the application. (New applicants only). Does the applicant lease the proposed location? *If yes, attach a copy of the Lease to the application. (New applicants or renewal applicants with lease changes). Lease End Date: _______________________ Is the premise(s) owned by a city or county, or is this a stadium, arena, convention center, theater, museum, amphitheater or other similar premises? *If yes, attach a copy of the Executed Agreement for alcoholic beverage services to the application. (New applicants or renewal applicants with changes). Executed Agreement End Date: ______________________ SECTION 10 – MANAGEMENT SERVICES DISCLOSURE Will any person/entity other than the owner(s) or partners be engaged or contracted to perform management or operational services? *If yes, you must complete and attach the Management Services Information (ABC-807) ABC-800 (Rev. 7.1.12) Page 11 of 13 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 FEIN_______________________ SECTION 11 – DETERMINATION OF FOOD SALES REQUIREMENT 1 A. Is your business also a licensed food service establishment as defined by K.S.A. 36-501? *If yes, proceed to “B” below. **If no, proceed to the next Section. Yes* No** Yes* No** Yes* No** Yes* No** Yes* No** Yes* No** 1 Food – means any raw, cooked or processed edible substance or ingredient, other than alcoholic liquor or cereal malt beverage used or intended to use or for sale, in whole or in part, for human consumption. B. Are you applying for or renewing a private club license? *If yes, select your private club class type below and answer the questions. **If no, proceed to “C” below. CLASS A CLUB: Do you have reciprocal agreements that are not listed in your charter? *If yes, attach copies of your reciprocal agreements outside those listed in your charter. Proceed to next Section. **If no, proceed to next Section. CLASS B CLUB: Do you own multiple Class B Clubs? (If yes, 50% food sales requirement applies). Do you have reciprocal agreements? (If yes, 50% food sales requirement applies). *If yes, attach copies of your reciprocal agreements. Proceed to “D” below. **If no, proceed to next Section. C. Is there a 30% food sales requirement in your county? *If yes, proceed to “D” below. **If no, proceed to the next Section. To check for food sales requirements in your county, go to: http://www.ksrevenue.org/abcwetdrymap.html D. Statement of Gross Receipts (select one): I am applying for a new license. I understand that I must meet the 30% food sales requirement during the license term. (50% food sales requirement for Class B Clubs with reciprocal agreements and/or multiple ownership). I am renewing my license. I understand that I must meet the 30% food sales requirement during the license term. (50% food sales requirement for Class B Clubs with reciprocal agreements and/or multiple ownership). Enter the following information: License Year: ____________ to ____________ Month/Year Month/Year soeriop Gross Receipts1: $____________________ Food Income2: $____________________ Percentage of Food Income: ____________% 1 Gross Receipts for Drinking Establishments, Caterers or Hotels – includes all sales of food and beverages sold on the premises Gross Receipts for Private Clubs – includes sales of any type made on the licensed premises including food, alcohol, membership fees, cover charges, vending machine concessions, video games and other sales. 2 Food Income – means the gross receipts from the sale of food on the licensed premises only and does not include income derived from the sale of items mixed with alcoholic liquor or cereal malt beverage. 1 ABC-800 (Rev. 7.1.12) Page 12 of 13 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 FEIN_______________________ SECTION 12 – AUTHORIZED PERSON TO DISCUSS MY LICENSE AND/OR APPLICATION WITH ABC Check one: I designate the following person. I designate the following person/agent as my primary contact. (Check this box only if indicated in Section 4). I do not wish to designate a person. Name Address Daytime Phone City State Zip Code E-Mail Address SECTION 13 – APPLICATION OATH Under penalties of perjury, I declare the information contained in this document and all application materials represents a true, accurate and complete disclosure of information. I hereby authorize disclosure and investigation of my financial records, including those held by third parties, to duly authorized agents of the Director of Alcoholic Beverage Control as necessary to determine qualification for licensure. I also authorize KDOR to send communications to the e-mail address provided on this form. Furthermore, if a Corporation or LLC, I appoint the Process Agent with Power of Attorney identified in Section 5, who is a United States citizen and a Kansas resident, upon whom process may be served in any action brought against it. __________________________________________________________________________________________________________________ Signature of Applicant Date __________________________________________________________________________________________________________________ Printed Name Title Clear Form ABC-800 (Rev. 7.1.12) Page 13 of 13 American LegalNet, Inc. www.FormsWorkFlow.com