New Mexico Regulation and Licensing Department Alcohol and Gaming Division P. O. Box 25101 ▪ Sant a Fe, New Mex ico 87504-5101 ▪ (505) 476-4875 ▪ Fax (505) 476-4595 Rev. 05/08 ▪ www.rld.state.nm.us/agd SPECIAL DISPENSER PERMIT APPLICATION THIS APPLICATION MUST BE RECEIVED BY THE DIVISION AT LEAST 10 DAYS PRIOR TO THE EVENT. INSTRUCTIONS Eligibility and requirements - Only the holder of a New Mexico Dispenser’s license may apply for and be issued a Special Dispenser Permit (SDP). All applications must be filled out completely and the licensee’s signature must be notarized. Incomplete applications may be returned to the licensee. A list of all servers who will be serving alcoholic beverages for this function must be submitted prior to AGD granting approval for any SDP. A detailed floor plan (8 ½ x 11) must be submitted showing exactly where the event is to be held. Floor plan must show location of bars, serving areas, entrances, exits and enclosed or barricaded serving areas must also be clearly marked. The floor plan must also include the total square footage for the proposed service area. Events that require a Public Celebration Permit - A Public Celebration is defined as any state or county fair, fiesta, cultural or artistic performance or professional athletic competition of a seasonal nature or activities held on an intermittent basis. Provide detailed information about the public celebration. Security - If security is deemed to be insufficient based upon the number of attendees, AGD may disapprove the application. A copy of all approved permits will be sent to the Special Investigations Division of the Department of Public Safety. They will notify you directly if they need additional information. Submission and fees - All applications and fees must be received by the Alcohol and Gaming Division at least 10 days prior to celebration. Submission of an application does not constitute approval. Fees processed are not refundable even if the event does not take place at the date and time for which the permit is issued. Dispensing of alcoholic beverages - Only the employees who are licensed servers, of the holder of the New Mexico dispenser’s liquor license who is issued a Special Dispenser Permit may sell, dispense, or serve the alcoholic beverages. Hours of Operation - Special Dispenser Permit’s cannot last longer than 12 hours for each day the permit is issued. Events held on Sundays - The local governing body where the event is to be held must have authorized Sunday Sales and the holder of the dispenser’s license must have a valid Sunday Sales Permit issued by the Alcohol and Gaming Division or must have a special concession issued from the local governing body pursuant to Section 60-6A-12(E) NMSA, 1978. Posting of Special Dispenser Permit at event - The Special Dispenser Permit and all legally required signs (i.e., pregnancy, firearms, minors, etc.) must be prominently posted at the approved location as outlined by the floor plan. The dispenser’s license being used must be located in the same local option district where the event will be held. The local governing body of the local option district must grant approval for the issuance of the permit. The local governing body includes city council, county clerk, mayor, etc. Attach required documentation - List of servers who will be at the event with their server permit number. A detailed floor plan designating restricted and unrestricted areas. Don’t forget to include the fee! American LegalNet, Inc. www.FormsWorkFlow.com New Mexico Regulation and Licensing Department Alcohol and Gaming Division P. O. Box 25101 ▪ Sant a Fe, New Mex ico 87504-5101 ▪ (505) 476-4875 ▪ Fax (505) 476-4595 ▪ www.rld.state.nm.us/agd Rev. 05/09 SPECIAL DISPENSER PERMIT APPLICATION (60-6A-12) Fee per day: ___ $50 Public Celebration ___ $25 Private Event (All fees are non-refundable) LICENSE HOLDER INFORMATION Business Name (DBA) ___________________________________________________Owner Name _____________________________ License Number _________________ Street Address: _______________________________________________________________City, State, Zip_____________________________________________________ Mailing Address _________________________________________________________ City, State, Zip__________________________________________________________ Phone # ________________________ Fax # ___________________________ Local Option District ____________________________________________________________ EVENT INFORMATION Description of Event______________________________________ Date(s) of Event ________________________ Begin Time ____________ End Time ______ Physical Address of Event_________________________________________________________________________ Number of Persons expected ____________ Description of Security ______________________________________________________________Number of Security personnel to be at this function________ Security Contact Name ______________________________________________________________ Telephone # ______________________________________ SPONSOR INFORMATION Sponsor of Event ________________________________ Contact Name ________________________ Signature _____________________ Phone _______________________ BUILDING OWNER APPROVAL Name (print) ____________________________________ Signature __________________________________ Phone __________________ Date ________________________ LICENSE HOLDER AND SERVER CERTIFICATION I, _______________________________ (Licensee) hereby certify that this event is within the same local option district as the dispenser’s license, that event is not within 300 feet of a church or school unless alcoholic beverages were sold there prior to July 1, 1981 or a waiver is obtained from the local governing body. I further certify that all persons providing the service of alcoholic beverages are server certified and that they are my employees and that ALL the information in this application is true and correct. NOTE: List of servers including name, server permit # and server expiration date must be attached to permit application. Licensee agrees that if any statements or representations herein are found to be false, the director may refuse to issue additional permits. Licensee Name (print) __________________________________________ Signature (Licensee Only) ___________________________________ Date ____________________ All profits derived from the sale of liquor will go only to the licensee. Only the owner or authorized person under this license may sign the permit. NOTARY INFORMATION Subscribed and Sworn before me this __________ day of ________________, 20 ____ Notary Public ______________________________________ Exp.___________________ LOCAL GOVERNING BODY APPROVAL Print Name _________________________________________ Title ______________________ Signature _____________________________ Date____________________ Alcohol and Gaming Division Use Only Approved by: Date: Permit Number: American LegalNet, Inc. www.FormsWorkFlow.com