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 FINGERPRINT AFFIDAVIT Type of License applied for _________________________________________________ License Number / Application Number ________________________________________ I, (print name) __________________________________________swear that the following information in this Affidavit is true and correct. I understand that if any information contained herein is false, or found to be false, the Alcohol & Gaming Division reserves the right to revoke the Liquor License or Resident Agent License that was issued in reliance on the exactness and truth of the information contained in this Affidavit. Yes Yes Yes No No No Are you at least 21 years of age? Have you ever been convicted of a felony? Have you ever been convicted of two separate misdemeanor or petty misdemeanor violations of the New Mexico Liquor Control Act in any Calendar year? Yes No N/A If convicted, have you obtained a pardon and have you been restored of civil rights? (Attach copy of pardon, if applicable.) Yes No Are you a citizen of the United States?____________________________________ If not, what Country? _____________________ Resident Alien Number: __________________ This form must be signed in the presence of a Notary Public. 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 _____________ Social Security Number: ___________-___________-___________ STATE OF NEW MEXICO, County of ____________________________________________ ________________________________, being duly sworn, says that he/she is the person referred to in this application and that the statements therein contained are true in every respect. Subscribed and sworn to before me this ______ day of ____________20 _____A.D. Witness my hand and seal hereunto attached. Signature of Notary Public________________________________________________________ My Commission Expires _________________________________________________________ For Alcohol and Gaming Division use only. _____ TEMPORARY LIQUOR LICENSE APPROVAL Approved by_______________________________________________________ Date ______________ _____ FINGERPRINT APPROVAL Approved by_______________________________________________________ Date ______________ American LegalNet, Inc. www.FormsWorkFlow.com