Change Of Structure Application - New Mexico Regulation And Licensing Department Page 7

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AGD Stamp
Revised 7/16
New Mexico Regulation and Licensing Department | Alcohol and Gaming Division
| Page 3B
PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595
CORPORATION-
NMSA §60-6B-2.A(4)
Name of Corporation: ____________________________________________________________________________________
(Attach certified copy of its Certificate of Incorporation and Articles of Incorporation. Foreign Corporations must also
include a certified copy of its New Mexico Certificate of Authority.)
Date of Incorporation: ________________________________________ In what State? ________________________________
Mailing Address of Corporate Office: ________________________________________________________________________
City: _____________________________________ State: _________ Zip: _____________ Phone: ______________________
Provide full names and addresses of all Officers and Directors of the Corporation, also the names and addresses of all
stockholders holding 10% or more in the Corporation. If a stockholder with 10% or more stock is any other legal entity,
complete the appropriate disclosure page for the stockholding entity.
List: % Stock Held | Title and Name of Officers, Directors and Stockholders |Complete Address
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
________|______________________________________________________________________________________________________________________________________
USE ADDITIONAL PAGES IF NECESSARY.
Has Corporation ever had a liquor license in which it held any interest in any State suspended or revoked?
No
Yes, if so,
___________________________________________________________________________________
provide details:
______________________________________________________________________________________________________________________________
:
List every liquor license in which the Corporation holds any interest, direct or indirect:
None
See Attached
As follows
_________
_____________________________________________________________________________________________
Has any principal Officer, Director or Shareholder that holds 10% or more of this Corporation ever been convicted of a felony?
___________________________________________________
No
Yes, detailed as follows: __________________
NOTE: Each individual Applicant, Partner, Officer, Director and Stockholder of 10% or more of stock in the
Corporation must submit a Personal Data Affidavit Form (page 6). All who own 10% or more must submit Fingerprints.
All Managing Partners and Directors must also be Server Certified.

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