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