DBA Name Change Application

New Mexico Regulation and Licensing Department PO Box 25101 Santa Fe, New Mexico 87504-5101 (505) 476-4875 Fax (505) 476-4595 www.rld.state.nm.us/alcoholandgaming ALCOHOL AND GAMING DIVISION CORPORATION or DBA NAME CHANGE APPLICATION Fee $50.00, included by check or money order ­ all application fees are non-refundable NMAC Regulation 15.11.23.9 A. CORPORATION NAME CHANGE: "The Licensee must also file with the department a copy of the application filed with the New Mexico Corporation Commission requesting a name change and a copy of the Certificate issued by the New Mexico Corporation Commission reflecting the name change." 15.11.23.9 B. BUSINESS NAME CHANGE: "Any Licensee that changes the name under which it operates a liquor license must file an application for change of DBA ("doing business as") name with the department. Please Print: Current DBA Name: Liquor License # Current Corporation Name: _______________________________________________________ Liquor License Owner Name: Location: City/State/Zip: Business Phone: _____________________ Email: ____________________________________ Mailing Address: Has there been any change in the ownership or operation of the licensee? Yes No If yes, explain: New Corporation or DBA Name Requested: Reason for Change: Effective Date of Name Change: Sign before a Notary Public: Submitted by the following Authorized Personnel: Print First Name: Owner Lessee Resident Agent Last: Signature:___________________________________ Title:____________________ Date:____________ NOTARY PUBLIC USE ONLY: (State of___________________, County of ________________________) SUBSCRIBED AND SWORN TO before me this ________________ day of ______________________________, 20______ By:_________________________________________________ Notary Public: _______________________________________ My Commission Expires:_______________________________ SEAL ALCOHOL & GAMING USE ONLY: Payment| Application Fee $_______________ Received on: _______________ Receipt No. _________________ Sunday Sales by: Drink Package Tax Hold/Citations:____________________________ Approved Disapproved Processed By: Date: American LegalNet, Inc. www.FormsWorkFlow.com Revised: 7/18/2016