Limited Partnership Or General Partnership Information Sheet-LLC-Corporation

AGD Stamp New Mexico Regulation and Licensing Department | Alcohol and Gaming Division | Page 3C Revised 5/16 PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595 LIMITED PARTNERSHIP OR GENERAL PARTNERSHIP - NMSA §60-6B-2.A(5) 1. Name of Limited Partnership or General Partnership: __________________________________________________________ 2. Date Partnership Formed (attach copy of Partnership Agreement): _________________________ 3. Date Partnership Registered (attach copy of Certificate): __________________________________ 4. Mailing Address: ______________________________________________________________________________________ City: __________________________ State: ________________ Zip: _________________ Phone: ______________________ 5. Names and addresses of all General and Limited Partners--full disclosure is required. If General Partner or Limited Partner is a Corporation, LLC, Trust or other General or Limited Partnership, complete the appropriate entity information page. GENERAL PARTNERS: LIST % Stock Held |Title |Name |Complete Address ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ LIMITED PARTNERS: LIST % Stock Held |Title |Name |Complete Address ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ ______|_________________________________________________________________________________________________ 6. Has this Partnership ever had a liquor license in which it held any interest in any State suspended or revoked? No Yes, detailed as follows: _______________________________________________________________________________________ _______________________________________________________________________________________________________ 7. List every liquor license in which this Partnership owns any interest, direct or indirect: None See Attached As follows: ______________________________________________________________________________________________________ 8. Has any principal Officer, Director or Shareholder that holds 10% or more of this Partnership ever been convicted of a felony? No Yes, detailed as follows: __________________________________________________________________________ NOTE: Each individual General or Limited Partner, must submit a complete Personal Data Affidavit Form (page 6). All who own 10% or more must submit Fingerprints. All Managing Partners, Directors must also be Server Certified. American LegalNet, Inc. www.FormsWorkFlow.com