Fingerprint Affidavit

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 AFFIDAVIT FOR FINGERPRINTS Print Name: Social Security Number: Type of License applied for: License Number / Application Number: I, (print name) , swear that the information provided in this Affidavit is true and correct. I understand that if any information contained herein is false, or found to be false, the Alcohol & Gaming Division reserves the right to revoke the Liquor License or Resident Agent License that was issued in reliance on the exactness and truth of the information contained in this Affidavit. Are you at least 21 years of age? Yes No Have you ever been convicted of a felony? Yes No Have you ever been convicted of two separate misdemeanor or petty misdemeanor violations of the New Mexico Liquor Control Act in any calendar year? Yes No If convicted, have you obtained a pardon? Yes No N/A and, Have your civil rights been restored? Yes No (Attach copy of pardon, if applicable.) Are you a Citizen of the United States? Yes No If not, what Country? Resident Alien Number: This form must be signed in the presence of a Notary Public. I, the undersigned, swear that the information contained in this application is true and correct to the best of my knowledge. Authorized Signature: NOTARY PUBLIC: State of Signed and sworn to before me on this day of Date: , County of , 20 , , - Title: by _______________________________________. Signature of Notary Public: My Commission Expires on: For Alcohol & Gaming Division Use Only: TEMPORARY LIQUOR LICENSE APPROVAL Approved by Director: FINGERPRINT APPROVAL Date: Revised 2/2016 American LegalNet, Inc. www.FormsWorkFlow.com SEAL