***Kansas Sales Tax Number: (Corporate Application Form

***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.