Page 2 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 Rev. 05/10 ▪ w w w. rl d. st at e. n m . u s /a g d PREMISES LOCATION, OWNERSHIP, AND DESCRIPTION SS-60-6B-10 1. The land and building which is proposed to be the licensed premises is (check one): Owned by Applicant _______ Leased by Applicant (attach copy of deed or lease) _______ Other (provide details) ______________________________________ 2. If the land and building are not owned by Applicant, indicate the following: A. Owner(s) ______________________________________________________________________________________________________________________ B. Date and term of lease__________________________________________________________________________________________________________ 3. Premises location is zoned (example C-1)___________________________________________________________________________________________________ If the premises is zoned, attach zoning statement from local government giving location address and type of zone, stating whether alcoholic beverages are allowed at proposed location. If there is no zoning, attach confirmation from local government indicating there is no zoning. 4. Distance from nearest church *(Property line of church to licensed premises—shortest distance). Miles/feet ________________ Name of church ____________________________ Address/location of church ___________________________________________ 5. Distance from nearest school *(Property line of school to licensed premises—shortest distance). Miles/feet ________________ Name of school ____________________________ Address/location of school ____________________________________________ 6. Distance from military installation *(Property line of military installation to licensed premises-shortest distance.) Miles ___________________ Name of Military Installation, circle one: Kirtland Air Force Base (Albuquerque), White Sands Missile Range (Las Cruces), Holloman Air Force Base (Alamogordo), Cannon Air Force Base (Clovis). 7. Attach, on a separate sheet, the detailed floor plan for each level (floor) where alcoholic beverages will be sold or consumed. Show exterior walls, doors, and interior walls. This will be the licensed premises. The floor plan should be no larger than 8 ½ x 11 inches, and must include the total square footage of premises. *If the distance is beyond 300 feet, but less than 400 feet, a registered engineer or licensed surveyor must complete a Survey Certificate showing the exact distance. 8. Type of Operation: Lounge __________ Restaurant __________ Package Grocery __________ Racetrack ________ Hotel _________ Other (specify) ________________________ 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