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 Page 1 ▪ w w w. rl d. st at e. n m . u s /a g d Rev. 05/10 LIQUOR LICENSE APPLICATION Application fee - $200.00 Fees are non-refundable. State Liquor License # ____________________________ Record Owner of Existing License ______________________________________________________________________ Application Number ______________________________ Current D/B/A Name _________________________________________________________________________________ Local option (AGD use)____________________________ Current Premises Address _____________________________________________________________________________ Application is for: Change of Stock ________ Change of Officers/Directors ________ Transfer Ownership of Existing License _______ Transfer Ownership and Location ________ Transfer Location _______ Other____________ Issue New License ______________ Type of License being applied for ______________________________________________________________________________________________________________ Applicant is: Individual _____________________ Corporation ____________________________ Partnership (General or Limited) ____________________________ Limited Liability Company ___________________________ NAME OF APPLICANT (company or individual) ADDRESS (including city, state, zip) TELEPHONE NUMBER _____________________________________________ _____________________________________________ ____________________________ _____________________________________________ _____________________________________________ ____________________________ D/B/A name to be used: ___________________________________________________________________________________ Phone number for licensed premises: _______________________________ Physical location where license is to be used: _____________________________________________________________________________________________________________________________ (Include street number / highway number / state road, city and county, state, and zip code) Mailing address: ________________________________________________________________________________________________________________ Are alcoholic beverages currently being dispensed at the proposed location? Yes _______ No ________ If yes, give license number and type ____________________________________________________ I, (print name) ___________________________________________________________________, as (title) ___________________________________________________ being first duly sworn upon oath deposes and says: that he/she is the applicant or is authorized by the applicant to make this application; that he/she has read the same; knows the contents therein contained are true. Applicant(s) agree(s) that if any statements or representations herein are found to be false, the director may refuse to issue or renew the license or may cause the license to be revoked at any time. You must sign and date this form in the presence of a notary public. Signature of Appplicant____________________________________________________________________________________________ Date__________________________________________________ Notary Public Use Only SUBSCRIBED AND SWORN TO before me this ______________ day of ______________________________, 20_________ by ___________________________________________________________ Notary Public _________________________________________________________________ My Commission Expires ____________________________________________________________________ Local Governing Body of: _______________________________________________________________________________ (City or County). Hearing held on ______________________ 20___________ Check one: Approved_________ Disapproved __________ City/County Official ______________________________________________________________________________ (Signature & Title) For Alcohol and Gaming Division Use Only Approved ____________ Disapproved ____________ Director Approval ___________________________________________________________________ Date __________________________________ American LegalNet, Inc. www.FormsWorkFlow.com