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 ( 5 0 5) 4 7 6- 4 5 9 5 ▪ ww w.rl d. stat e. n m .u s / AG D COMMON CARRIER LICENSE APPLICATION *3 Year License Fee - $50.00 All Application Fees Are Non-Refundable *All licenses are issued for a period of three (3) years, fee schedule below: 1st Year_______ 2nd Year _____ 3rd Year_____ 7/1/10-6/30/13 7/1/11-6/30/13 7/1/12-6/30/13 $33.20 $16.60 $50.00 Name of Carrier _______________________________________________________________________ Owner/Manager _______________________________________________________________________ Business Location ____________________________ City _____________State_____ Zip ___________ Mailing Address (if different) __________________ City _____________ State______ Zip ___________ Phone Number ____________________________________ Fax Number _________________________ I, the undersigned, swear that the information on this application form is true and correct to the best of my knowledge. Print Name__________________________________________________ Title _____________________ Authorized Signature __________________________________________ Date ____________________ Alcohol and Gaming Division Use Only: Approved By __________________________________ Date _____________ License # ____________ Revision date: 06/2010 American LegalNet, Inc. www.FormsWorkFlow.com