NM RegulatioN aNd liceNsiNg depaRtMeNt alcoHol & gaMiNg diVisioN MailiNg addRess: po Box 25101 saNta fe, NM 87504-5101 pHysical addRess: toNey aNaya BuildiNg 2550 ceRRillos Road, 2Nd flooR saNta fe, NM pH: (505) 476-4875 fax: (505) 476-4595 www.Rld.state.NM.us/alcoHolaNdgaMiNg CLUB- Non-Profit Organization CHANGE OF OFFICER APPLICATION American LegalNet, Inc. www.FormsWorkFlow.com New Mexico Regulation and Licensing Department Alcohol and Gaming Division PO Box 25101 Santa Fe, NM 87504-5101 (505) 476-4875 Fax (505) 476-4595 www.rld.state.nm.us/alcoholandg aming Rev. 02/16 APPLICATION FOR CHANGE OF OFFICERS ­ NON-PROFIT ORGANIZATIONS Please keep a copy of the application for your records. If you have any questions, please contact us at (505) 476-4875 or website: www.rld.state.us/alcoholandgaming ALL HOLDERS OF A CLUB LIQUOR LICENSE to submit this application yearly, when a change in club officers takes place. 1. Change of Officers Application (COA)-Clubs (Non-Profit Organizations): Must contain current Officer/Director information. Make sure the application is completed and signed before a notary public. 2. Submit copy of the Non-profit Corporate Report that was submitted to SOSCBS, records must match. Officers and Directors listed on the COA should match the names of the current Officers and Directors on any inquiry done on-line at this web address: http://www.sos.state.nm.us/Business_Services/ or contact them at (505) 827-4511 or 800-4773632 or email: corporations@state.nm.us. Corporation must be in Good Standing with the Office of the Secretary of State Business Services Division (SOSCBS). 3. MINUTES: You must submit a signed copy of the Minutes, verifying the election of the new Officers/Directors when you submit your Application for Change of Officers. 4. Resident Agent: only if the current Resident Agent is replaced, a Designated Resident Agent application must be submitted. An Officer of the Corporation should appoint the resident agent and sign/notarize the top portion . The newly appointed Resident Agent accepts the appointment and must sign/date in front of a notary on the bottom portion. 5. Personal Data Information and Affidavit: complete for each new individual. Fingerprints: The following must be submitted for each Officer/Director/Resident Agent listed on #1 above, only if they have never been fingerprinted for this Agency before: a. Register with 3M Cogent online at www.cogentid.com b. If fingerprints cannot be done by Livescan with Cogent, must submit two fingerprint cards signed and completed (make sure all blanks are filled in). c. A $44.00 cashier's check or money order payable to 3M Cogent. DO NOT COMBINE FEES IF YOU ARE SUBMITTING CARDS FOR MORE THAN ONE PERSON. ONLY CASHIERS CHECK OR MONEY ORDERS WILL BE ACCEPTED MADE OUT TO 3M COGENT. d. A Law Enforcement Certificate e. A Personal Data Information and Affidavit Form ­ Must always be submitted for every person listed on the COA and Resident Agent f. A Fingerprint Affidavit FBI Notice for all fingerprints submitted to this agency - Applicant Notification and Record Challenge Officials at the governmental institutions and other entities authorized to submit fingerprints and receive FBI identification records under this authority must notify the individuals fingerprinted that the fingerprints will be used to check the criminal history records of the FBI. The officials making the determination of suitability for licensing or employment shall provide the applicants the opportunity to complete, or challenge the accuracy of, the information contained in the FBI identification record. These officials also must advise the applicants that procedures for obtaining a change, correction, or updating of an FBI identification record are set forth in Title 28, C.F.R., § 16.34. Officials making such determinations should not deny the license or employment based on information in the record until the applicant has been afforded a reasonable time to correct or complete the record, or has declined to do so. (Title 42, U.S.C., §14616, Article IV (c); Title 28 C.F.R., § 50.12 (b)) DESIGNATED RESIDENT AGENT PAGE: 1. 2. As part of the application, an Applicant who is not a sole proprietor is required to submit information regarding a New Mexico resident, who is not a felon, who has the power and authority to make decisions related to liquor sales and operations and upon whom the director may serve any notice related to the operation of the license. The Resident Agent form must be completed, signed, and notarized in two places. First Section ­ the Appointment section, is to be completed and signed by an officer, director or a shareholder, holding a 10% interest or more, who has been fingerprint qualified. This signature must be notarized. In this section, the applicant will list the name of the chosen Resident Agent. Second Section ­ the Acceptance section must be completed and signed by the individual who has been designated as the Resident Agent by the Applicant. The signature of the Resident Agent must also be notarized. The individual designated as Resident Agent must complete a Personal Information and Affidavit Form. Note: All entities must file a new application for Resident Agent each time there is a change in agents. Each Resident Agent MUST BE: Fingerprinted; Hold a current Servers Certification Permit, attach a copy to application; an individual, at least 21 years of age, and at time of application; A Resident of the State of New Mexico and remain a resident of New Mexico; Cannot have been convicted of a felony or of two misdemeanor violations of the Liquor Control Act in any calendar year. American LegalNet, Inc. www.FormsWorkFlow.com 3. 4. CLUB ­ CHANGE OF OFFICER CHECKLIST Date Received: _______________ License No. ______________ Expires on:________________ Name of Applicant: _____________________________________________________________________________________ D/B/A Name: __________________________________________________________________________________________ Location Address: ______________________________________________________________________________________ Mailing Address: _______________________________________________________________________________________ NEW OFFICERS / DIRECTORS: OFFICERS /DIRECTORS OF RECORD: _____________________________________________________________________________________________________ _____________________________________________________________________________________________