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 3 Rev. 05/10 LIMITED PARTNERSHIP OR GENERAL PARTNERSHIP INFORMATION SHEET SS 60-6B-2(A)(b) 1. Name of Limited Partnership or General Partnership __________________________________________________________________________________________ 2. Date Partnership formed (attach copy of Partnership Agreement) ___________/________/____________________________________________________________ 3. Date Partnership registered (attach copy of certificate) ___________________/________/_____________________________________________________________ 4. Mailing address: Street _____________________________________________ City _________________ State _______ Zip ________ Phone __________________ 5. Names and addresses of all General and Limited Partners—full disclosure is required. If General Partner or Limited Partner is a corporation, LLC, Trust or other General or Limited Partnership, complete the appropriate entity information page. General Partners Name Address % Interest _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Limited Partners Name Address % Interest _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ 6. Has this Partnership ever had a liquor license in which it held any interest in any State suspended or revoked, or has the Partnership been denied the issuance of a liquor license? No___ Yes ___ If Yes, provide details: _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ 7. List every liquor license in which this Partnership owns any interest, direct or indirect: _______________________________________________________________________________________________________________________________________ NOTE: For each General or Limited Partner who is an individual, complete the Personal Data Information Form (page 6), and for each person attach two (2) completed fingerprints cards (available from the Alcohol and Gaming Division) along with fees and supporting documentation. Fingerprints must be taken by City Police, State Police, or Sheriff (any state). 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 LIMITED LIABILITY COMPANY SS 60-6B-2A 1. Name of Limited Liability Company ____________________________________________________________________________________________________ 2. Date company formed (attach copy of Operating Agreement) ___________/________/____________________________________________________________ 3. Date company registered (attach copy of certificate and Article of Organization)________/_________/________________________________________________ 4. Mailing Address: Street _________________________________________ City _________________ State ________ Zip _________ Phone ________________ 5. Names and addresses of all Members – full disclosure is required. If a Member is a corporation, Trust, Limited Liability Company, General or Limited Partnership, complete the appropriate entity information page. LIST ALL MEMBERS AND MANAGERS Name Title Address % of interest/contribution __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ 6. Has this Limited Liability Company ever had a liquor license in which it held any interest in any State suspended or revoked, or has the Limited Liability Company been denied the issuance of a liquor license? No___ Yes ___ If Yes, provide details: _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ 7. List every liquor license in which this Limited Liability Company owns any interest, direct or indirect: _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ NOTE: For each Member who is an individual, complete the Personal Data Information Form (page 6), and for each person attach two (2) completed fingerprints cards (available from the Alcohol and Gaming Division) along with fees and supporting documentation. Fingerprints must be taken by City Police, State Police or Sheriff (any state). 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 TRUST 1. Name of Trust ______________________________________________________________________________________________________________________ 2. Date Trust formed (attach copy of entire Trust Agreement) ___________/________/_______________________________________________________________ 3. Mailing Address: Street __________________________________________ City _________________ State ________ Zip _________ Phone ________________ 4. Names and addresses of all Trustees and each Beneficiary of the Trust – full disclosure is required. If a Trustee or Beneficiary is a corporation, Limited Liability Company or a General or Limited Partnership, complete the appropriate corporation information on Page 4, or appropriate Partnership Statement (Page 3). LIST ALL TRUSTEES AND BENEFICIARIES Name Title Address % of interest __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ 5. Has this Trust ever had a liquor license in which it held any interest in any State suspended or revoked, or has the Trust been denied the issuance of a liquor license? No___ Yes ___ If Yes, provide details: __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ 6. List every liquor license in which this Trust owns any interest, direct or indirect _____________________________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________________ NOTE: For each Trustee and/or Beneficiary who are individuals, complete the Personal Data Information Form (page 6), and for each person attach two (2) completed fingerprints cards (available from the Alcohol and Gaming Division) along with fees and supporting documentation. Fingerprints must be taken by City Police, State Police or Sheriff (any state). 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 4 Rev. 05/10 CORPORATION SS 60-6B-2 Name of Corporation: ___________________________________________________________________________________________________________________ (Corporations must attach certified copy of its Certificate of Incorporation and Articles of Incorporation. Foreign corporations must also include a certified copy of its New Mexico certificate of authority.) Date of Incorporation: ________________________________________________ In what State? ______________________________________________________ Mailing Address of Corporate Office: _________________________________________ City ________________ State _____ Zip ________ Phone _____________ Provide complete names and addresses of all officers and directors of the Corporation, also the names and addresses of all stockholders of 10% or more of the stock in the Corporation. If a stockholder of 10% or more of the stock is any other legal entity, complete the appropriate disclosure page for the stockholding entity. Name and Title of Officers, Directors and Stockholders Complete Address % Stock Held _______________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________ USE ADDITIONAL PAGES IF NECESSARY. Has this Corporation ever had a liquor license in which it held any interest in any State suspended or revoked, or has the Corporation been denied the issuance of a liquor license? No___ Yes ___ If Yes, provide details: __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ List every liquor license in which the Corporation holds any interest, direct or indirect: _______________________________________________________________ Has this Corporation ever been convicted of a felony? No___ Yes ___ If Yes, provide details: __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ** Note: For each individual applicant, partner, officer, director, and stockholder of 10% or more of stock in corporation, complete the Personal Data Information Form (page 6) and attach two completed sets of fingerprint cards (available from the Alcohol and Gaming Division) along with fees and supporting documentation. Fingerprints must be taken by City Police, State Police, or Sheriff (any state). 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