Change Of Structure Application - New Mexico Regulation And Licensing Department Page 10

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AGD Stamp
Revised 5/16
New Mexico Regulation and Licensing Department | Alcohol and Gaming Division
| Page 5
PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595
AGD USE ONLY: Payment| Application Fee $______________ Received on: ______________ Receipt No. __________________
DESIGNATION OF RESIDENT AGENT – $50.00 non-refundable fee
Name of Corp./LLC/Partnership/Trust (print) ______________________________________________ Liquor License # ______________
D/B/A Name: ____________________________________________________________________________________________________
KNOW ALL MEN BY THESE PRESENT that the above-named Company hereby makes, constitutes and A
:
PPOINTS
___________________________________________________________, to act as Resident Agent
(Print Appointee’s Name)
on behalf of the company and accept service of process for all purposes relating to the sales and service of the alcoholic
beverages, including orders and notices of the Director and/or the Division.
(Check one)
Initial Resident Agent
Adding another Resident Agent
Replacing Resident Agent, remove: __________________________
Appointed and Submitted by an Authorized Officer of Corporation/ LLC/ Partnership/ Trust:
Sign in the presence of a Notary Public.
Signature: _____________________________________________________________ Title___________________________________
ACKNOWLEDGEMENT BY OFFICER APPOINTING AGENT
N
P
U
O
: (State of ___________________________, County of ________________________________)
OTARY
UBLIC
SE
NLY
before me, this ____________ day of _____________________________, 20_______
SUBSCRIBED & SWORN TO
By:
Notary Public:
____________________________________________
_______________________________________
SEAL
My Commission Expires:____________________________
ACCEPTANCE OF APPOINTMENT BY RESIDENT AGENT
I, (print name) ____________________________________________, accept the appointment as Resident Agent, and by accepting this
appointment hereby Certify that I am a Resident of the State of New Mexico. I am also the Resident Agent for the following New Mexico
Liquor License(s): ___________________, ___________________, __________________, _________________, _________________
Residence Address: ______________________________________________________________________________________________
City: ___________________________________ State: ____________________ Zip: ________________ Phone # _________________
Alcohol Server Permit # ____________________________________ Expires on: ______________________, Required to Attach Copy
Sign in the presence of a Notary Public.
Signature of Resident Agent: ______________________________________________________ Date: ___________________________
ACKNOWLEDGEMENT
N
P
U
O
: (State of ___________________________, County of ________________________________)
OTARY
UBLIC
SE
NLY
before me, this ____________ day of _____________________________, 20_______
SUBSCRIBED & SWORN TO
By:
Notary Public:
____________________________________________
_______________________________________
SEAL
My Commission Expires:____________________________
F
A
G
D
U
O
:
Fingerprints submitted on: ________________ Cleared on: ____________
OR
LCOHOL AND
AMING
IVISION
SE
NLY
Approved
Disapproved
Signed by Director: _________________________________________________________ Date: _____________________

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