Nmgcb Transport Form - Application To Transport Gaming Device Or Gaming Media

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Application to Transport Gaming Device or Gaming Media

New Mexico Gaming Control Board

Board Assigned Control Number:

4900 Alameda Blvd. NE, Albuquerque, New Mexico 87113

Phone: (505) 841-9700

EMAIL: GCB-TRANSPORT@STATE.NM.US

Check one:

Transport Into State

Transport Outside State

Transport Within State

See back of this form for instructions and regulations.

SHIPPER INFORMATION

Name:

License Number (If Any):

Address:

Date Shipped:

Arrival Date:

Contact name:

Carrier:

Contact number:

Carrier Phone #:

Carrier Address:

Mode of Transportation:

ATTACH A COPY OF BILL OF LADING; IF ONE IS NOT AVAILABLE, ATTACH BILL OF SALE

DESTINATION INFORMATION

Receiver Name:

License Number:

Receiver Address: _____________________________________________________________________________________

Estimated Arrival Date: __________ Time: _______________

Attached

APPROVAL BY RECEIVING JURISDICTON

(for transportation outside state only)

Attach written approval by jurisdiction to which the gaming device will be shipped.

STATEMENT BY OUT-OF-STATE PURCHASER

I certify, under penalty of perjury, that the gaming device(s)

described in this form will be used only for lawful purposes, and the information contained herein is accurate.

Signature: ___________________________ Date: ______________

Subscribed and sworn By Me This _____ Day Of ____ 20___

REASON FOR SHIPMENT

In ___________________ County, _____________________

Sale

Lease

Signed: ___________________________________________

Demonstration

Notary Public

(Contact NMGCB first, for special requirements)

My Commission Expires: ________________

Other (explain) ______________________________

QUANTITY SHIPPED

STATEMENT BY APPLICANT

A person who, in an application, book or record, required to be maintained by the Gaming Control Act (60-2E-

1 to 60-2E-61 NMSA 1978) or by a regulation adopted under that act or in a report required to be submitted by that act or a regulation adopted under that

act, knowingly makes a statement or entry that is false or misleading or fails to maintain or make an entry the person knows is required to be maintained or

made is guilty of a fourth degree felony and shall be sentenced pursuant to the provisions of section 31-18-15 NMSA 1978. (60-2E-54 NMSA 1978)

Subscribed and sworn By Me This _____ Day Of ____ 20___

Applicant Signature: _____________________________________

In __________________ County, ______________________

Date: _________________

Signed: ___________________________________________

Notary Public

My Commission Expires: ________________

NMGCB Enforcement Use Only

Date of Inspection: ______________, Was the shipment in compliance? Yes:  No: 

Enforcement Personnel Name: ____________________________ Date: ____________

NOTES: _______________________________________________________________