Change Of Structure Application - New Mexico Regulation And Licensing Department Page 8

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AGD Stamp
Revised 5/16
New Mexico Regulation and Licensing Department | Alcohol and Gaming Division
| Page 3C
PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595
-
LIMITED PARTNERSHIP OR GENERAL PARTNERSHIP
NMSA §60-6B-2.A(5)
1. Name of Limited Partnership or General Partnership: __________________________________________________________
2. Date Partnership Formed (attach copy of Partnership Agreement): _________________________
3. Date Partnership Registered (attach copy of Certificate): __________________________________
4. Mailing Address: ______________________________________________________________________________________
City: __________________________ State: ________________ Zip: _________________ Phone: ______________________
5. Names and addresses of all General and Limited Partners—full disclosure is required. If General Partner or Limited Partner is
a Corporation, LLC, Trust or other General or Limited Partnership, complete the appropriate entity information page.
G
P
: L
% Stock Held |Title |Name |Complete Address
ENERAL
ARTNERS
IST
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
L
P
: L
% Stock Held |Title |Name |Complete Address
IMITED
ARTNERS
IST
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
______|_________________________________________________________________________________________________
?
6. Has this Partnership ever had a liquor license in which it held any interest in any State suspended or revoked
No
Yes,
detailed as follows: _______________________________________________________________________________________
_______________________________________________________________________________________________________
7. List every liquor license in which this Partnership owns any interest, direct or indirect:
None
See Attached
As follows:
_________
_____________________________________________________________________________________________
8. Has any principal Officer, Director or Shareholder that holds 10% or more of this Partnership ever been convicted of a felony?
No
Yes, detailed as follows: __________________________________________________________________________
NOTE: Each individual General or Limited Partner, must submit a complete Personal Data Affidavit Form (page 6). All
who own 10% or more must submit Fingerprints. All Managing Partners, Directors must also be Server Certified.

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