Complaint Form

New Mexico Regulation and Licensing Department ALCOHOL AND GAMING DIVISION P O Box 251 01 S an ta Fe, New Mexi co 8750 4-51 01 ( 505) 476 - 4875 F ax (505) 476 -4595 www.r ld .st at e.nm.u s/ a lco ho lan d gam in g COMPLAINT REPORT The Regulation and Licensing Department Alcohol & Gaming Division works closely with the Special Investigations Unit (SIU) of the State of New Mexico Department of Public Safety, to enforce the provisions of the Liquor Control Act. Violations of the Act by liquor license holders can result in fines and/or suspension of the license. Three violations within a 12-month period can result in revocation of a liquor license. Please help us by reporting when you observe a licensed liquor establishment or its employees violating state law or failing in their obligations to the community. In filing a complaint, it is important that you provide us with as much information as possible, so that SIU investigators will be able to pursue your complaint. Thank you for your assistance. Your Name: _________________________________________________ Date: ____________________ Your Street Address: ___________________________________________________________________ City: ______________________________________ State: _____________ Zip: ___________________ How may we contact you? Phone: ___________________________ E-mail: _____________________________________________ We will respect your confidentiality. If you wish to remain anonymous, please check here: _______________ The Liquor License Holder you wish to comment or complain about: Business Name:________________________________________________________________ Location: _____________________________________________________________________ Street: ___________________________________________ City: ________________________ Type of Business: (check all that apply) Licensed Un-Licensed Bar Restaurant Package Goods Retailer Other: ____________________________ Provide the date, time, individuals involved and events of the incident below, use additional pages if necessary: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ You may submit your comments or complaints on-line through the AGD website, or mail this form to RLD|Alcohol and Gaming Division, PO Box 25101, Santa Fe, NM 87504-5101. Revised 9/2016 American LegalNet, Inc. www.FormsWorkFlow.com