Corporation

AGD Stamp New Mexico Regulation and Licensing Department | Alcohol and Gaming Division | Page 3B Revised 5/16 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 | Name and Title 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. American LegalNet, Inc. www.FormsWorkFlow.com