New Mexico Regulation and Licensing Department ALCOHOL AND GAMING DIVISION T o n ey A na ya B uil d i n g ▪ 2 5 5 0 C er r il l o s R oa d ▪ S a nt a F e, N e w M ex i c o 8 7 5 0 5 (5 0 5 ) 4 7 6 -4 8 7 5 ▪ F a x ( 50 5 ) 4 7 6 -4 5 9 5 ▪ w w w . r l d. st a t e. n m. u s / AG D ALCOHOL SERVER PERMIT DUPLICATE REQUEST FORM Attach money order or cashiers check in the amount of $10.00 made payable to the Alcohol & Gaming Division. No personal checks will be accepted. Incomplete applications will be returned unprocessed. All fees are non-refundable. (Please Print) First Name _________________________Middle ________________ Last_______________________ Social Security Number ________________________________________________________________ Date of Birth: ________________________________________________________________________ Current Mailing Address _______________________________________________________________ City ____________________________________ State ___________________ Zip________________ Phone Number _______________________________________________________________________ Driver’s License #______________________________________ State of Issuance: _______________ Current Place of Employment: __________________________________________________________ Reason for replacement: _______________________________________________________________ Note: If your last name has changed due to marriage, divorce or other legal reason, you must attach a copy of the applicable document (marriage certificate, divorce decree, etc). Server’s Signature: ____________________________________________ Date: _________________ Submit application to: Alcohol and Gaming Division, 2550 Cerrillos Road, Second Floor, Santa Fe, New Mexico 87505 Or mail to: Alcohol and Gaming Division, P.O. Box 25101, Santa Fe, New Mexico 87504-5101 ALCOHOL AND GAMING DIVISION USE ONLY Permit Number Expiration Date Processed By Today’s Date Pending Citations or Holds Revision date: 08/2010 American LegalNet, Inc. www.FormsWorkFlow.com