Form Abc-280-6s - Employee Registration Form - Department Of Revenue - Kansas

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KANSAS DEPARTMENT OF REVENUE
Alcoholic Beverage Control Division
EMPLOYEE REGISTRATION
Name of Establishment
License No.
_ _ - _ _ _ - _ _ _ _ - _ _
Address
City
Zip Code
Phone No. (_ _ _) - _ _ _ - _ _ _ _
List all personnel involved in the mixing, dispensing or serving of alcoholic liquor
PLEASE SPECIFY MANAGERS
*FOR RETAIL LIQUOR STORES - LIST ALL EMPLOYEES
FULL NAME OF EMPLOYEE - PLEASE PRINT
POSITION
RACE
Sex
DATE OF BIRTH
SOCIAL SECURITY NO.
(Optional)
LAST
FIRST
MI
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
B/W/C/M
W/B/H/A/I/
M/F
POSITION CODES: (B) Bartender (W) Waitress/Waiter (C) Clerk
(M) Manager
CIRCLE APPROPRIATE CODE
RACE CODES:
(W) White
(B) Black
(H) Hispanic
(A) Asian or Pacific Islander
(I) Indian or Native Alaskan
TO THE STATE DIRECTOR:
I certify that the persons whose name(s) appear on this form, are qualified to be employed in a licensed establishment. I further certify that
whenever a new person is employed, the establishment will notify the Director as required by Rules and Regulations.
Dated this ________________ day of __________________
__________________________________________
(Day)
(Month)
(Year)
Licensee or Manager Signature
Send To: Director, Alcoholic Beverage Control
Customer Relations/Licensing
rd
915 SW Harrison, 3
Fl. Rm. 381
Topeka, KS 66612-2001
ABC-280-6S (Rev. 5/00)
KEEP A COPY FOR YOUR RECORDS

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