Change Of Structure Application - New Mexico Regulation And Licensing Department Page 4

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AGD Stamp
New Mexico Regulation and Licensing Department  Alcohol and Gaming Division |
Rev.5/16
Page 1
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. ___________________
Application Number: __________________________
CHANGE OF STRUCTURE APPLICATION
$200.00
Application Fee, non-refundable.
NM Liquor License # __________________
Type of License:
Expires on: __________________________
Record Owner of Existing License: ________________________________________________________________________
Current D/B/A Name: ___________________________________________________________________________________
Current Premises Address: ______________________________________________________________________________
Check appropriate boxes:
Change of Structure
APPLYING FOR:
Other:_______________________________________________________________
Applicant Changing Entity:
Individual
Limited Liability Company
Corporation
Partnership (General/Limited)
WAS:
Individual
Limited Liability Company
Corporation
Partnership
NOW:
(General/Limited)
APPLICANT NAME - Individual/Company:
ADDRESS (including city, state, zip)
______________________________________________________________________________________________
______________________________________________________________________________________________
D/B/A Name to be used:
____________________________________________________ Business Phone #:
________________________
Email Address
(required): __________________________________________________________________________________________
Physical location where license is to be used
: (Include Street # / Highway # / State Road, City, State, and Zip Code)
_______________________________________________________________________________________________
County of:
_________________________________________________________________________________
________________________________
________________________________________________________________________________
Mailing Address:
Are alcoholic beverages currently being dispensed
Yes
No If Yes, License # / Type:
at the proposed location?
__________________
Agent/Contact Person: _____________________________ Phone#:
Email:
___________________
____________________________________
I, (print name) ________________________________________________, as (title) ___________________________________________
being first duly sworn upon oath deposes and says: that he/she is the applicant or is authorized by the applicant to make this application;
that he/she has read the same; knows the contents therein contained are true. Applicant(s) agree(s) that if any statements or representations
herein are found to be false, the Director may refuse to issue or renew the license or may cause the license to be revoked at any time.
Sign before a Notary Public:
Signature of Applicant:_______________________________________________________ Date:_______________________
N
P
U
O
: (State of ___________________________, County of ________________________________)
OTARY
UBLIC
SE
NLY
SUBSCRIBED AND SWORN TO before me this ______________ day of ______________________________, 20______
By:____________________________________________
Notary Public: _______________________________________
SEAL
My Commission Expires:______________________________
F
A
G
D
U
O
:
Approved
Disapproved
OR
LCOHOL AND
AMING
IVISION
SE
NLY
Signed by Director: ____________________________________________________________ Date: _____________________

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