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 ▪ w w w. rl d. st at e. n m . u s /a g d Page 5 Rev. 05/10 DESIGNATION OF RESIDENT AGENT Fee $50. (Excludes non-profit organizations.) Name of Corporation/LLC/Partnership/Trust (print) _______________________________________________________________________ Liquor License # __________________ D/B/A Name ______________________________________________________________________________________________________________________________________ KNOW ALL MEN BY THESE PRESENT that the company named on this form hereby makes, constitutes and appoints_________________________________________________ to act as Resident Agent on behalf of the company and accept service of process for all purposes relating to the sales and service of the alcoholic beverages, including orders and notices of the Director and/or the Division, and to have power of attorney to exercise full authority, control, and responsibility for the conduct of all business transactions of the company within the State relative to the sale of alcoholic beverages under authority of this license. You must sign and date this form in the presence of a notary public. Signature of Officer of Corporation/LLC/Partnership/Trust___________________________________________________________ Title___________________________________ ACKNOWLEDGEMENT FOR COMPANY State of _____________________________________________________________________ County of ____________________________________________________________ SUBSCRIBED AND SWORN TO before me this ____________ Day of ________________________, 20_________ by (appointing officer print name) _________________________ Notary Public ________________________________________________________________________________ My Commission Expires _________________________________ ACCEPTANCE I, (print name) _________________________________________, hereby accept the appointment as Resident Agent. I am a resident of the State of New Mexico. I am the Resident Agent for the following numbered New Mexico Liquor License(s): ____________, ____________, ___________, ___________, ___________, __________, ___________________ Residence Address: _______________________________________________________ City _____________________ State ________ Zip ___________ Phone # _____________ You must sign and date this form in the presence of a notary public. Signature of Resident Agent ________________________________________________________________ Expiration Date of Servers Certification____________________________ (Copy of permit required) ACKNOWLEDGEMENT FOR NATURAL PERSONS State of ________________________________________________________________ County of _________________________________________________________________ SUBSCRIBED AND SWORN TO before me this _____________ Day of ____________________, 20______ by (accepting RA print name) ________________________________ Notary Public __________________________________________________________ My Commission Expires __________________________________________ For Alcohol and Gaming Division Use Only Approved ______ Disapproved ______ Director Approval _______________________________________________________________________Date _______________________ Return this form to the Alcohol and Gaming Division, 2550 Cerrillos Road, Santa Fe, New Mexico 87505, if using overnight delivery. American LegalNet, Inc. www.FormsWorkFlow.com 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 ▪ w w w. rl d. st at e. n m . u s /a g d Page 6 Rev. 05/10 PERSONAL DATA INFORMATION AND AFFIDAVIT Liquor License # ____________________ or Application #_________________ INSTRUCTIONS: Submit this page for each individual applicant, each officer and director of a corporation, each stockholder (individual) owning 10% or more of the stock in Applicant Corporation, each individual limited or general partner, and each resident agent for a corporation, and each manager and member of LLC with 10% or more interest. Make additional copies of this page if necessary. Name (print) First _____________________________ Last __________________________ Birth date: ____/_____/______ Birthplace: _________________________ Residence address __________________________________________________________ City _______________________ State _________ Zip _________________ Business address: _________________________________________________________________________________ Business phone: _________________________ SS #_____-_____-_________Driver's license # __________________ State of issue _______ Citizenship __________ Resident Alien #__________________________ Yes No Are you married? Yes No Has your spouse ever been convicted of a felony in any jurisdiction? If yes, provide details: _________________________________________________ If you have been known by any other name, attach a list showing dates and reason for other name(s). (Example: maiden name). Attach additional pages if necessary. Name Date of change Reason for Change List every liquor license by number and State in which you directly or indirectly own any interest: ________________________________________________________ Yes No Have you been convicted of a felony? If yes, provide details: __________________________________________________________________________ Yes No N/A Has the Governor restored to you the privilege to receive and hold a liquor license? If yes, attach copy of documentation. No Have you been convicted of two separate misdemeanor violations of the New Mexico Liquor Control Act in any calendar year? Yes If yes, provide details: _____________________________________________________________________________________________________________________ No Have you ever had an application for a liquor license denied or had a liquor license in which you held any interest in any state suspended or revoked? Yes If yes, provide details: _____________________________________________________________________________________________________________________ No Are you at least 21 years of age? Yes Be sure that all questions have been answered. You must sign and date this form in the presence of a notary public. I, (print name) _____________________________________________________________swear that the information contained on this form is true, and understand that if any information contained herein is false or found to be false, the Division may revoke the liquor license issued under this application. Affiant Signature ____________________________________________________________________________ Date ________________________________________ _______________________________________________________________________________________________________________________________________ NOTARY PUBLIC USE ONLY SUBSCRIBED AND SWORN TO before me this ____________Day of ___________________________ 20_____________ by ____________________________________________ Notary Public ______________________________________________________________________________ My Commission Expires ______________________________________ ** Each person required to complete this page and required to submit fingerprints must attach one (2 cards) completed set of fingerprints on cards (available from the Alcohol and Gaming Division) along with fees and supporting documentation. Fingerprints must be taken by City Police, or State Police, or Sheriff (any state) $44.00 cashier’s check or money order payable to the Department of Public Safety must accompany EACH SET OF FINGERPRINTS. Return this form to the Alcohol and Gaming Division, 2550 Cerrillos Road, Santa Fe, New Mexico 87505, if using overnight delivery. American LegalNet, Inc. www.FormsWorkFlow.com 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 ▪ w w w. rl d. st at e. n m . u s /a g d Rev. 05/10 SUNDAY SALES APPLICATION Non-transferable Indicate the type of license you are applying for. If applying for both, mark both: Sunday Sales BY THE DRINK ___________________ (Fee: $100.00) Liquor License # ___________________ Sunday Sales PACKAGE ___________________ (Fee: $100.00) Application # ______________________ 1. Type of Liquor License applied for (print): _______ 2. DBA Name (print): 3. Name of applicant: 4. Physical location of licensed premises. Street address: 5. Mailing address: City: _____________________________________ State: ______________ Zip: ________________ __________ _______ City: __________________________ State: __________ Zip: ___________ 6. Local Option District (city or county where license is located) ___________________________________________________________________________________ The holder of a license that allows sales of alcoholic beverages by the drink may obtain a permit for the sale, service, or consumption of alcoholic beverages by the drink on a licensed premises on Sundays, between the hours of 12:00 noon to 12:00 midnight (Restaurant License holders see ** below). Sunday Sales by the drink are only permitted in those local option districts in which Sunday Sales have been approved by the voter in the at local option district. The holder of a license that allows package sales of alcoholic beverages for the off-premises consumption may obtain a permit for the sale of alcoholic beverages in unbroken packages for off-premises consumption on Sundays between the hours of 12:00 noon and 12:00 midnight in those local option districts that permit Sunday Package Sales. **Hours for sale, service, or consumption on Sunday for Restaurant License: 12:00 noon until 11:00 p.m. or until sales and service of food ceases, whichever is earlier. Licensee Signature _____________________________________________________________________________________________ Date _________________ For Alcohol and Gaming Division Use Only Approved By _____________________________________________________________________________________________________________ Date Return this form to the Alcohol and Gaming Division, 2550 Cerrillos Road, Santa Fe, New Mexico 87505, if using overnight delivery. American LegalNet, Inc. www.FormsWorkFlow.com 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 STATEMENT OF DEBT CLEARANCE Applicant for the transfer or lease of a liquor license must circulate this statement among all LIQUOR WHOLESALERS who have provided alcoholic beverages to the licensee and obtain certification that all debts owing have been paid or satisfactory arrangements for payment have been made. SUBMIT ORIGINALS ONLY. PHOTOCOPIES OF THESE PAGES ARE NOT ACCEPTABLE CERTIFICATION BY WHOLESALERS It is certified that all debts owed by the owner of record or the lessee of Liquor License No. have been paid or satisfactory arrangements for payment have been made and that in the interim period prior to issuance of a license to the new owner or lessee all sales made to this license will be on a cash basis only. It is further certified that any lien on this license has been satisfied. #6815 Gruet Winery 8400 Pan American NE Albuquerque, New Mexico 87113 (505) 821-0055 Print Name:__________________ #6820 Tularosa Vineyards 23 Coyote Canyon Road Tularosa, New Mexico 88352 (505) 585-4414 Print Name:___________________ #6823 La Chiripada Winery P.O. Box 191 Dixon, New Mexico 87527 (505) 579-4437 Print Name:__________________ Signature: ___________________ Signature: ____________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #6824 Madison Vineyards & Winery HC 72 Box 490 Dixon, New Mexico 87527 (505) 421-8028 Print Name:__________________ #6830 La Vina Winery 4201 South Highway 28 La Union, New Mexico 88021 (505) 882-7632 Print Name:__________________ #6831 Milagro Vineyards, Incorporated P.O. Box 1205 Corrales, New Mexico 87048 (505) 898-3998 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #6833 Corrales Winery P.O. Box 527 Corrales, New Mexico 87048 (505) 898-5165 Print Name:__________________ #6834 Anazasi Fields P.O. Box 712 Placitas, New Mexico 87403 (505) 867-3062 Print Name:__________________ #6835 New Mexico Wineries, Inc. P.O. Box 1180 Deming, New Mexico 88030 (505) 546-9324 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ Page 1 STATEMENT OF DEBT CLEARANCE New Mexico Regulation and Licensing Department – Alcohol and Gaming Division P.O. Box 25101 Santa Fe, New Mexico 87504 (505) 476-4875 - Fax (505) 476-4595 Revised 02/11 American LegalNet, Inc. www.FormsWorkFlow.com #6836 Black Mesa Winery P.O. Box 308 Velarde, New Mexico 87582 (505) 852-2820 Print Name:__________________ #6838 Bees Brothers Company 619 Nowicki Lane SW Albuquerque, New Mexico 87105 (505) 877-4887 Print Name:__________________ #6839 Ponderosa Valley Winery, Inc. 3171 Highway 290 Ponderosa, New Mexico 87044 (505) 834-7487 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: ______________________ #6844 Wines of New Mexico, Inc. P.O. Box 1611 Ruidoso, New Mexico 88345 (505) 630-9003 Print Name:__________________ #6845 Wines of the San Juan 233 Highway 511 Blanco, New Mexico 87412 (505) 632-0879 Print Name:___________________ #6846 Ritchie-Slater Winery #10 County Road B 3 Angel Fire, New Mexico 87710 (505) 377-6658 Print Name:__________________ Signature: ___________________ Signature: ____________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #6851 Luna Rossa Winery P.O. Box 1507 Deming, New Mexico 88030-1507 (505) 546-7948 Print Name:__________________ #6852 Tierra Encantada Vineyards & Winery 3560 Luck Circle NW Albuquerque, New Mexico 87107 (505) 343-1956 Print Name:__________________ #6854 Heart of The Desert Wines Eagle Ranch, 7288 Highway 54/70 Alamogordo, New Mexico 88310 (505) 434-0035 Print Name:___________________ Signature: ___________________ Signature: ___________________ Signature: ____________________ Date: _______________________ Date: _______________________ Date: _______________________ #6855 Cottonwood Winery 1 East Cottonwood Road Artesia, New Mexico 88210 (505) 308-9391 Print Name:__________________ #6857 Guadalupe Vineyards P.O. Box 400 San Fidel, New Mexico 87049 (505) 552-0082 Print Name:___________________ #6858 Falcon Ventures, Inc. 3159 Plaza Blanca Santa FE, New Mexico 87507 (505) 438-0945 Signature: ___________________ Signature: ____________________ Signature: ____________________ Date: _______________________ Date: _______________________ #6859 Acequia Vineyards & Winery P.O. Box 62 Corrales, New Mexico 87048-0062 (505) 264-1656 Print Name:__________________ #6862 Pecos Flavors Winery 305 North Main Roswell, New Mexico 88201 (575) 627-6265 Print Name:__________________ Date: ________________________ #6863 Casa Rondena Winery 733 Chavez Road NW Albuquerque, New Mexico 87107 (505) 344-5911 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #6864 Don Quixote Winery 236 Rio Bravo Los Alamos, New Mexico 87544 (505) 672-3581 Print Name:__________________ #6865 San Tomas Vineyards / Pistachio 7320 US Highway 54-70 Alamogordo, New Mexico 88310 (575) 437-0602 Print Name:___________________ #6866 Casa Abril Vineyards & Winery 01 Camino Abril Algodones, New Mexico 87001 (505) 771-0696 Print Name:__________________ Signature: ___________________ Signature: ____________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ Page 2 Print Name:___________________ STATEMENT OF DEBT CLEARANCE New Mexico Regulation and Licensing Department – Alcohol and Gaming Division P.O. Box 25101 Santa Fe, New Mexico 87504 (505) 476-4875 - Fax (505) 476-4595 Revised 02/11 American LegalNet, Inc. www.FormsWorkFlow.com #6867 La Esperanza Vineyard, LLC HC 71 Box 1377 San Lorenzo, New Mexico 88041 (575) 259-9523 Print Name:__________________ #6868 Amaro Winery 2480 Roadrunner Parkway Las Cruces, New Mexico 88011 (575) 525-0241 Print Name:___________________ #6869 Jacona Valley Winery, Inc 311 County Road 84 Santa Fe, New Mexico 87506 (505) 455-1984 Print Name:___________________ Signature: ___________________ Signature: ____________________ Signature: ____________________ Date: _______________________ Date: _______________________ Date: _______________________ #6871 Noisy Water Winery 2342 Sudderth Drive Ruidoso, New Mexico 88345 (575) 257-9335 Print Name:__________________ #6872 Bellanzi Winery 516 E Grant Hwy Hachita, New Mexico 88040 (815) 568-8018 Print Name:___________________ Signature: ___________________ Signature: ____________________ Date: _______________________ Date: _______________________ #7003 Gallup Sales Co. 530 East 66th Avenue Gallup, New Mexico 87301 (505) 863-5241 Print Name:__________________ #7034 Howard A. Rubin, Incorporated 623 ½ Camino Rancheros Santa Fe, New Mexico 87505-2837 (505) 988-1728 Print Name:___________________ #7087 Southern Wine & Spirits 1601 Commercial NE Albuquerque, New Mexico 87102 (505) 246-3122 Print Name:__________________ Signature: ___________________ Signature: ____________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #7097 National Distributing Company Inc. 5920 Office Blvd. NE Albuquerque, New Mexico 87109 (505) 345-4492 Print Name:__________________ #7098 Premier Distributing Co. Clovis 1017 & 1019 East Santa Fe Blvd. Clovis, New Mexico 88101 (575) 762-4489 Print Name:__________________ #7099 Premier Distributing Co. Albuquerque 4321 Yale Blvd., N.E. Albuquerque, New Mexico 87107 (505) 344-0287 Print Name:___________________ Signature: ___________________ Signature: ___________________ Signature: ____________________ Date: _______________________ Date: _______________________ Date: _______________________ #7100 Premier Distributing Co. Santa Fe 2680 Sawmill Road Santa Fe, New Mexico 87505 (505) 473-0595 Print Name:__________________ #7108 Premier Distributing, Co. Gallup 3524 Sonastee Gallup, New Mexico 87107 (505) 863-6708 Print Name:___________________ Signature: ___________________ Signature: ____________________ Date: _______________________ Date: _______________________ #7109 Premier Distributing Co. 1200 Troy King Road Farmington, New Mexico 87401 (505) 327-6371 Print Name:__________________ #7110 Synergy Fine Wines 149 Mountain Park Place, NW Unit B Albuquerque, New Mexico 87102 (505) 792-9730 Print Name:__________________ #7119 Santa Fe Brewing Company P.O. Box 29773 Santa Fe, New Mexico 87592-9773 (505) 424-3333 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ Page 3 STATEMENT OF DEBT CLEARANCE New Mexico Regulation and Licensing Department – Alcohol and Gaming Division P.O. Box 25101 Santa Fe, New Mexico 87504 (505) 476-4875 - Fax (505) 476-4595 Revised 02/11 American LegalNet, Inc. www.FormsWorkFlow.com #7123 Fiasco Fine Wine Inc. 20 Bisbee Court Santa Fe, New Mexico 87508 (505) 438-2500 Print Name:__________________ #7126 Tractor Brewing Company 120 Nelson Lane, Unit C Los Lunas, New Mexico, 87031 (505) 866-0477 Print Name:___________________ #7127 Marble Distributing 4056 Cerrillos Road, Suite F-6 Santa Fe, New Mexico 87507 (505) 424-1882 Print Name:__________________ Signature: ___________________ Signature: ____________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #7129 L & F Distributors 2200 North Atkinson Avenue Roswell, New Mexico 88201 (575) 622-0380 Print Name:__________________ #7132 Pinion Distributing 352 Sagebrush Drive Corrales, New Mexico 87048 (505) 250-4509 Print Name:___________________ #7133 Crianza Wines Distributing 7900 Lorraine Court NE Suite 1 Albuquerque, New Mexico 87113 (505) 821-5852 Print Name:__________________ Signature: ___________________ Signature: ____________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #7134 Beer Direct PO Box 3567 Moriarty, New Mexico 87035 (505) 832-2337 Print Name:__________________ #7137 Global Wine Connection, Inc 518 Old Santa Fe Trail Suite 209 Santa Fe, New Mexico 87505 (505) 440-9926 Print Name:__________________ #7138 Floating World, Inc 320 Tesuque Drive Santa Fe, New Mexico 87505 (505) 989-4104 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #7139 Premier Distributing Company 380 Alliance Drive Las Cruces, New Mexico 88005 (505) 344-0287 (ABQ) Print Name:__________________ #7140 Southwest Wines & Spirits 3836 Hawkins Street, NE Albuquerque, New Mexico 87109 (505) 546-9324 Print Name:__________________ #7141 Admiral Beverage Corporation 1018 South Atkinson Roswell, New Mexico 88203 (307) 347-4201 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #7142 Admiral Beverage Corporation 6000 South Main Street Mesilla Park, New Mexico 88047 (307) 347-4201 Print Name:__________________ #7143 Admiral Beverage Corporation 7 Paseo de River Santa Fe, New Mexico 87507 (307) 347-4201 Print Name:__________________ #7144 Admiral Beverage Corporation 1801 East Broadway Farmington, New Mexico 87401 (307) 347-4201 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ Page 4 STATEMENT OF DEBT CLEARANCE New Mexico Regulation and Licensing Department – Alcohol and Gaming Division P.O. Box 25101 Santa Fe, New Mexico 87504 (505) 476-4875 - Fax (505) 476-4595 Revised 02/11 American LegalNet, Inc. www.FormsWorkFlow.com #7145 Admiral Beverage Corporation 701 Comanche NE Albuquerque, New Mexico 87107 (307) 347-4201 Print Name:__________________ #7146 Comanche Creek Brewing PO Box 375 Eagle Nest, New Mexico 87718 (575) 377-2337 Print Name:__________________ #7147 The Way of Sake 207 A North Guadalupe Street Santa Fe, New Mexico 87501 (505) 231-2743 Print Name:__________________ Signature: ___________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ Date: _______________________ #7148 La Cumbre Brewing Co 3313 Girard Boulevard NE Albuquerque, New Mexico 87107 (505) 331-9740 Print Name:__________________ #7149 Indio-Hispano Native Foods LLC PO Box 9905 Albuquerque, New Mexico 87119-9905 (505) 247-0862 Print Name:__________________ Signature: ___________________ Signature: ___________________ Date: _______________________ Date: _______________________ CERTIFICATION OF CURRENT LICENSE OWNER OR AGENT The undersigned certifies that the following wholesalers are the only wholesalers from whom alcoholic beverages were purchased. PRINT NAME OF CURRENT LICENSEE OR APPROVED AGENT: SIGNATURE: Page 5 DATE: STATEMENT OF DEBT CLEARANCE New Mexico Regulation and Licensing Department – Alcohol and Gaming Division P.O. Box 25101 Santa Fe, New Mexico 87504 (505) 476-4875 - Fax (505) 476-4595 Revised 02/11 American LegalNet, Inc. www.FormsWorkFlow.com