Personal Data Information And Affidavit

AGD Stamp New Mexico Regulation and Licensing Department | Alcohol and Gaming Division | Page 6 Revised 7/16 PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595 AGD use only| Fingerprints #/Received on: _______________ Cleared on: _______________ Server Permit# ___________ Expires:___________ Liquor License # ____________________ or Application #______________________ PERSONAL DATA AFFIDAVIT INSTRUCTIONS: Submit this page for Each Individual Applicant, Each Principal Officer and Director of a Corporation, Each Stockholder (individual) owning 10% or more of the stock in Applicant Corporation, Each individual Limited Liability or General Partner, Each Resident Agent for a Corporation, and Each Manager and Member of LLC with 10% or more interest. Make additional copies of this page if necessary. Print clearly. First Name: ___________________________________ Last Name: ________________________________________ SS #_______-_______-____________ Birth Date: ______/_______/_________ Contact #:______________________________ Email Address: __________________________________________________________________________________________ Business Address: _______________________________________________________ Business Phone: ___________________ Residence Address: _______________________________________________________________________________________ City: _______________________________ State: _____________________________ Zip Code:_________________________ Driver's License, Issued in the State of: _____________________________ DL No.___________________________________ U.S. Citizenship or Citizen of: _____________________________ Resident Alien #____________________________ Male Female Are you at least 21 years of age? Yes No Are you married? Yes No If yes, has your spouse ever been convicted of a felony in any jurisdiction? Yes No If yes, provide details: _____________________________________________________________________________________ ALIAS: If you have been known by any other name, list date and reason for other name(s). Attach additional pages if necessary. Name(s) Used: ____________________________________________ Date(s) of Change:_______________________________ Reason for Change (such as Marriage/Divorce/Decree): __________________________________________________________ Have you been Convicted of a Felony? Yes No If yes, provide details:__________________________________ and, N/A has the Governor restored your privilege to receive and hold a Liquor License? Yes, copy attached No Have you been convicted of two separate misdemeanor violations of the New Mexico Liquor Control Act in any calendar year? Yes No If yes, provide details: Have you ever had an Application for a Liquor License, in any State, suspended or revoked? Yes No If yes, provide details: _________________________________________________________________________________________________ Do you directly or indirectly own any interest in a Liquor License? Yes, the following: __________________________________ Yes, see attached, listing all License No.(s) and State(s) No If your response is Yes to the following two questions, you need to be alcohol server certified. 1. Will you manage, direct or control the sale of alcohol? Yes No 2. Will you be present on the licensed premises on a regular basis? Yes No You must sign before a Notary Public and ALL questions must be answered. I, (print name) swear that I have answered each question honestly, that the information provided in my responses are true and correct, and understand that if any information contained herein is false or found to be false, the Division may revoke the Liquor License issued under this Application. Affiant Signature: Note: For fingerprint procedures, review information provided on the website. Date: ________________ NOTARY PUBLIC USE ONLY: (State of ___________________________, County of ________________________________) SUBSCRIBED & SWORN TO before me, this __________ day of _____________________, 20_____ By:___________________________________ Notary Public: ______________________________ My Commission Expires:____________________ SEAL American LegalNet, Inc. www.FormsWorkFlow.com