New Mexico Regulation and Licensing Department Alcohol and Gaming Division P.O. Box 251 0 1 ▪ S a nt a F e, N ew M ex i c o 8 7 50 4 - 51 01 ▪ ( 5 05 ) 47 6 - 4 87 5 ▪ F a x ( 50 5 ) 4 7 6 -4 5 9 5 Page 1 ▪ w w w. rl d. st at e. n m . u s /a g d Rev. 05/10 LEASE APPLICATION Application fee - $250.00 Fees are non-refundable. State Liquor License # ____________________________ Record Owner of Existing License ______________________________________________________________________ Application Number ______________________________ Current D/B/A Name _________________________________________________________________________________ Local option (AGD use)____________________________ Current Premises Address _____________________________________________________________________________ APPLICANT IS: INDIVIDUAL __________ CORPORATION __________ PARTNERSHIP (GENERAL OR LIMITED) __________ LIMITED LIABILITY COMPANY ___________ OTHER__________ NAME OF LEASE APPLICANT (company or individual) ADDRESS (INCLUDING CITY, STATE, ZIP) TELEPHONE NUMBER ___________________________________________________________________ ___________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _________________________________ _________________________________ DBA Name of Lessee: _________________________________________________________________________________________________________ New Mexico Tax ID #____________________________________________ (Attach copy of Tax ID Registration Certificate) Mailing Address for Lessee: ___________________________________________________________________________________________________ Phone Number of Licensed Premise: _____________________________________________ Actual address where license is to be used _____________________________________________________________________________________________________________________ (Include street number / highway number / state road, city and county, state, and zip code) Attach a copy of liquor license lease agreement between licensee and applicant. Effective date of Lease: ______________ Term of Lease: _________________ You must sign and date this form in the presence of a notary public. I, (print name) _________________________________________________________________, as (title) ________________________________________________ being first duly sworn upon oath deposes and says: that he/she is the applicant or is authorized by the applicant to make this application; that he/she has read the same; knows the contents therein contained are true. Applicant(s) agree(s) that if any statements or representations herein are found to be false, the director may refuse to issue or renew the license or may cause the license to be revoked at any time. Signature of Appplicant____________________________________________________________________________________________Date__________________________________________________ Notary Public Use Only SUBSCRIBED AND SWORN TO before me this ______________ day of ______________________________, 20_________ by ___________________________________________________________ Notary Public _________________________________________________________________ My Commission Expires ____________________________________________________________________ For Alcohol and Gaming Division Use Only Approved ____________ Disapproved ____________ Director Approval ___________________________________________________________________ Date ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com