Change Of Structure Application - New Mexico Regulation And Licensing Department Page 6

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AGD Stamp
Revised 5/16
New Mexico Regulation and Licensing Department | Alcohol and Gaming Division
| Page 3A
PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595
LIMITED LIABILITY COMPANY-
NMSA §60-6B-2.A(6)
1. Name of Limited Liability Company: ___________________________________________________________________
2. Company Formed on: _____________________, with copy of Operating Agreement attached.
3. Company Registered on: __________________, with a copy of Certificate and Article of Organization attached.
4. Mailing Address: _______________________________________________________________________________________
City: ______________________________________State: ____________ Zip: ____________ Phone:____________________
5. LIST ALL MEMBERS AND MANAGERS; Names and addresses of all Members – full disclosure is required.
If a Member is a Corporation, Trust, Limited Liability Company, General or Limited Partnership, complete the appropriate entity
information page.
List % of Interest/Contribution |Title |Name |Complete Address
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
____|__________________________________________________________________________________________
6. Has this LLC ever had a liquor license in which it held any interest in any State suspended or revoked?
No
Yes, if so,
provide details: __________________________________________________________________________________________
_______________________________________________________________________________________________________
:
7. List every Liquor License in which this LLC owns any interest, direct or indirect:
None
See Attached
As follows
_________
_____________________________________________________________________________________________
1. Has any principal Officer, Director or Shareholder that holds 10% or more of this LLC ever been convicted of a felony?
__________________________________________________________
No
Yes, detailed as follows: __________
NOTE: Each individual Member must submit a Personal Data Affidavit form (page 6). All Members who
own 10% or more must submit Fingerprints. All Managing Members must also be Server Certified
.

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