Change Of Structure Application - New Mexico Regulation And Licensing Department Page 11
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11AGD Stamp
Revised 7/16
New Mexico Regulation and Licensing Department | Alcohol and Gaming Division
| Page 6
PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595
|
: _______________
_______________
___________
___________
AGD use only
Fingerprints #/Received on
Cleared on:
Server Permit#
Expires:
Liquor
License # ____________________ or Application #______________________
PERSONAL DATA AFFIDAVIT
INSTRUCTIONS: Submit this page for Each Individual Applicant, Each Principal Officer and Director of a Corporation, Each Stockholder
(individual) owning 10% or more of the stock in Applicant Corporation, Each individual Limited Liability or General Partner, 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.
Print clearly.
: ___________________________________
________________________________________
First Name
Last Name:
SS #_______-_______-____________ Birth Date: ______/_______/_________ Contact #:______________________________
Email Address: __________________________________________________________________________________________
Business Address: _______________________________________________________ Business Phone: ___________________
Residence Address: _______________________________________________________________________________________
City: _______________________________ State: _____________________________ Zip Code:_________________________
Driver's License, Issued in the State of: _____________________________ DL No.___________________________________
U.S. Citizenship or
Citizen of: _____________________________ Resident Alien #____________________________
Male
Female
Are you at least 21 years of age?
Yes
No
Are you married?
Yes
No If yes, has your spouse ever been convicted of a felony in any jurisdiction?
Yes
No
If yes, provide details: _____________________________________________________________________________________
ALIAS: If you have been known by any other name, list date and reason for other name(s). Attach additional pages if necessary.
Name(s) Used: ____________________________________________ Date(s) of Change:_______________________________
Reason for Change (such as Marriage/Divorce/Decree): __________________________________________________________
Have you been Convicted of a Felony?
Yes
No If yes, provide details:__________________________________ and,
has the Governor restored your privilege to receive and hold a Liquor License?
Yes, copy attached
No
N/A
Have you been convicted of two separate misdemeanor violations of the New Mexico Liquor Control Act in any calendar year?
Yes
No If yes, provide details:
Have you ever had an Application for a Liquor License, in any State, suspended or revoked?
Yes
No If yes, provide
details: _________________________________________________________________________________________________
Do you directly or indirectly own any interest in a Liquor License?
Yes, the following: __________________________________
Yes, see attached, listing all License No.(s) and State(s)
No
If your response is Yes to the following two questions, you need to be alcohol server certified.
Will you manage, direct or control the sale of alcohol?
1.
Yes
No
Will you be present on the licensed premises on a regular basis?
2.
Yes
No
You must sign before a Notary Public and ALL questions must be answered.
I, (print name)
swear that I have answered each
question honestly, that the information provided in my responses are true and correct, 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:
Note: For fingerprint procedures, review information provided on the website.
N
P
U
O
: (State of ___________________________, County of ________________________________)
OTARY
UBLIC
SE
NLY
before me, this __________ day of _____________________, 20_____
SUBSCRIBED & SWORN TO
SEAL
By:
Notary Public:
___________________________________
______________________________
My Commission Expires:____________________
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