***Kansas Sales Tax Number: (Corporate Application Form) APPLICATION FOR LICENSE TO RETAIL CEREAL MALT BEVERAGES SHAWNEE COUNTY, KANSAS ___________, 20__ TO THE BOARD OF COUNTY COMMISSIONERS OF SHAWNEE COUNTY, KANSAS. On behalf of the ______________________________________________________________________ corporation whose principal place of business is ___________________________________________________________________________ and under authority of the resolution of the Board of Directors of said corporation, I hereby apply for a license to sell retail cereal malt beverages in conformity with the laws of the State of Kansas and the rules and regulations prescribed and hereafter to be prescribed by you relating to the sale or distribution of cereal malt beverages on behalf of said corporation; for the purpose of securing such license, I make the following statements under oath: 1. The proposed licensee is 5. I hereby certify with regard to each of the persons named in number 2 ______________________________________________ above the following statements are true: corporation with principal place of business at (a) None of them has within the last two years from this date been __________________________________________________________ convicted of ____________________________________ (1) A felony The resident agent is (2) A crime involving moral turpitude _______________________________________________ (3) Drunkenness with offices at (4) Driving a motor vehicle while under the influence of __________________________________________________________ intoxicating liquor ____________________________________ (5) Violation of any state or federal intoxicating liquor law Said corporation was incorporated on ________________ If any of the above have been convicted of any of the above in the state of ___________________________________ specified offenses, the details are set out hereinafter. If incorporated in Kansas, a copy of the Articles of Incorporation is on file with the Secretary of State. (b) No manager, officer or director or any stockholder owning in Yes ( ) No ( ). the aggregate more than 25% of the stock of the corporation 2. The following is the full and complete list of officers, directors and has been an officer, manager or director, or a stockholder stockholders owning in the aggregate more than 25 percent of corporate owning in the aggregate more than 25% of the stock of a stock, together with their positions and addresses, ages and dates of Corporation which: birth. __________________________________________________________ (1) has had a retailer’s license revoked under K.S.A. 41__________________________________________________________ 2708 and amendments thereto; or __________________________________________________________ (2) has been convicted of a violation of The Drinking __________________________________________________________ Establishment Act or the Cereal Malt Beverage Laws of the __________________________________________________________ State. __________________________________________________________ __________________________________________________________ 6. The place of business will be conducted by the following manager(s): Name _________________________________________ __________________________________________________________ Residence Address ______ _______________________________________________ 3. The premises for which the license is desired are located Date of birth_____________________________________ at_____________________________________________ _______________________________________________ (a) The legal description is of the premises is _______________________________________________ (b) The street number is I hereby certify that with regard to this above-named manager the _______________________________________________ statement contained in number 5 above is in every respect true. If not, (c) The building is described as the details are set out hereinafter. _______________________________________________ The corporate business under the license will be conducted in the name 7. This application is for a license to retail cereal malt beverages for of the corporation or in the following name: consumption on the premises ( ). For a license to retail cereal malt _______________________________________________ beverages in original and unopened containers and not for consumption on the premises. ( ). 4. The name(s) and address(es) of the owner or owners of the premises upon which the place of business is located is/are 8. Applicants social security __________________________________________________________ number____________________________________ __________________________________________________________ __________________________________________________________ ____________ I,_________________________________________________________________________________________________________ (Name and position with corporation) on behalf of the above-named applicant, hereby agree to comply with all laws of the State of Kansas, and all rules and regulations prescribed and hereafter to be prescribed by you, relating to the sale and distribution of cereal malt beverages, and do hereby agree to purchase all cereal malt beverages from a wholesaler, licensed and bonded under the laws of the State of Kansas, and do hereby further consent to the immediate revocation of the cereal malt beverage license issued pursuant to this application by the proper officials for the violation of any such laws, rules or regulations. ____________________________________ (Corporation) (Corporate Seal) By _______________________________________________ (Signature and position of individual making application on behalf of corporation) ATTEST: _______________________________________, Secretary of Corporation STATE OF KANSAS, COUNTY OF SHAWNEE, ss. I, ___________________________________________________________ of the ________________________________________________________ (Signature and official position) (Name of corporation) solemnly swear that I have read the contents of this application, and that all information and answers herein contained are complete and true. So help me God. __________________________________________ (Signature and official position) SUBSCRIBED AND SWORN TO before me this _____ day of _________________________, A.D. 20__ Character of official administering oath: _____________________________________________________ My commission expires on ____ day of _______________________________, A.D. _____ APPLICATION APPROVED this ____________ day of _________________________________, A.D. 20__ By ______________________________, Chair--Board of County Commissioners of Shawnee County, Kansas A License fee of $ ________ is enclosed herewith.
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