Fingerprint Affadavit (Temporary Liquor License)
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Fingerprint Affadavit (Temporary Liquor License) Form. This is a New Mexico form and can be use in Regulation And Licensing Department Statewide.
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Tags: Fingerprint Affadavit (Temporary Liquor License), New Mexico Statewide, Regulation And Licensing Department
Bill Richardson
GOVERNOR
Gary Tomada
DIRECTOR
Lillian Martinez
DEPUTY DIRECTOR
ALCOHOL & GAMING DIVISION
2550 Cerrillos Rd. Santa Fe, NM 87505
PO Box 25101 Santa Fe, NM 87504-5101
Fax (505) 476-4595
(505) 476-4875
www.rld.state.nm.us/agd
FINGERPRINT AFFIDAVIT
(Temporary Liquor License)
Type of License Applied for ______________________________________________________
Liquor License Number __________________________________________________________
I, (please print)___________________________________, swear that the following information
contained in this affidavit is true and correct. I understand that if any information contained in
this affidavit is false, the Director of the Alcohol and Gaming Division shall deny the application
for a liquor license and the Director shall revoke any temporary license issued under the
provisions of the Liquor Control Act. I further understand that any temporary license shall be
surrendered immediately upon order of the Director of the Alcohol and Gaming Division. I also
understand that when the Director of the Alcohol and Gaming Division determines that a false
affidavit has been filed, the Director shall refer the matter to the Attorney General or District
Attorney for prosecution of perjury pursuant to Section 60-6B-2(D), NMSA 1973 (1993 Supp.).
1. I have never been convicted of a felony.
2. I have not been convicted of two separate misdemeanor or petty misdemeanor
violations of the New Mexico Control Act in any calendar year.
County of _____________________________________________________________________
State of _______________________________________________________________________
Applicant’s Signature __________________________ Social Security # ______-____-________
Notary Public Use Only
SUBSCRIBED AND SWORN TO before me this _______Day of ___________ 200__________
Notary Public __________________________________________________________________
My Commission expires__________________________________________________________
______________________________________________________________________________
Alcohol & Gaming Division Use Only
Hearing Officer _________________________________ Date _________________________________
Approved By ___________________________________ Date _________________________________
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