Alcohol Server Replacement Request Form

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/alcoholandg aming ALCOHOL AND GAMING DIVISION ALCOHOL SERVER PERMIT DUPLICATE REQUEST FORM Fee: $10.00, by Money Order or Cashier's Check Only, all fees non-refundable made payable to: Alcohol & Gaming Division Must attach a copy of your government issued ID (Driver License, Identification Card or Passport). No personal checks or cash accepted. Incomplete Application will be returned. Please Print: First Name: _________________________Middle: ____________________ Last: _________________________ Driver's License ­ State of Issuance: ___________________ License No.: ________________________________ Social Security Number: _____________________________________ Date of Birth: ______________________ Current Mailing Address: _______________________________________________________________________ City: _____________________________________ State: _____________________ Zip: ___________________ Phone Number: _____________________________ Cell Number: ___________________________________ Email Address: _______________________________________________________________________________ Current Place of Employment: ___________________________________________________________________ Check applicable box: Reason for Replacement: Illegible/Damaged Lost Stolen Other: _________________________ Name Change; If your name has changed due to marriage, divorce or other legal name change, you must attach supporting documentation such as: marriage certificate, divorce decree, court order/decree, etc. As required, I have included: Copy of my Government Issued I.D. $10.00 Money Order or Cashier's Check Server's Signature: _______________________________________________ Date: ______________________ Mail application to: PO Box 25101 Santa Fe, NM 87504-5101 Physical Location: Toney Anaya Building, 2550 Cerrillos Road Santa Fe, NM 87504 Phone: (505) 476-4875 Fax: (505) 476-4595 ALCOHOL AND GAMING DIVISION USE ONLY: Permit Number Permit Expires On: Processed By: Today's Date: Pending Citations or Holds Revised 3.30.16 American LegalNet, Inc. www.FormsWorkFlow.com