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 _____Fee $50.00 All Application Fees Are Non-Refundable DBA NAME CHANGE APPLICATION Regulation 15 NMAC 11.2.3.9.2 Current DBA Name ____________________ Phone # __________ Liquor License # ________ Liquor License Owner Name (First) _________________________ (Last) _________________ License Location _____________________________ City ________________ State _____ Zip ______ Mailing Address (if different) __________________________ City __________ State _____Zip ______ Current Approved DBA (Please Print) _____________________________________________________ New DBA Name Requested (Please Print) __________________________________________________ Reason for Change_____________________________________________________________________ Has there been any change in the ownership or operation of the licensee? Yes ________ No ___________ If yes, explain _________________________________________________________________________ Effective Date of DBA Name Change ______________________________________________________ Submitted by (Please Print) First _____________________________ Last ________________________ Signature ___________________________________ Title ____________________ Date ____________ Alcohol & Gaming Use Only Sunday Sales Yes_______ No_______ Approved _______ Disapproved ________ Approved By ______________________________________________ Date ______________________ Revision date: 03/2011 American LegalNet, Inc. www.FormsWorkFlow.com