Common Carrier License Application

New Mexico Regulation and Licensing Department Toney Anaya Building 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 COMMON CARRIER LICENSE APPLICATION agd use only | Application # _________________ 3 Year License: 7/01/2016 ­ 6/30/2019, all application fees are non-refundable STAGGERED FEE, CHECK THE BOX FOR YEAR APPLYING FOR: 1st year |fy2016 $50.00 2nd year |fy2017 $33.20 3rd year |fy2018 $16.60 I am a Qualified Applicant, and have included the Application Fee of $_____________________ Name of Carrier: ______________________________________________________________________ Owner Name: _________________________________________________________________________ Physical Address: ______________________________________________________________________ Mailing Address: ______________________________________________________________________ Phone Number: ____________________ Fax: ____________________ Cell: ______________________ E-Mail: ______________________________________________________________________________ I, the undersigned, swear that I am authorized, under the active License attached, to obtain this permit and that the information on this application form is true and correct, to the best of my knowledge. You must sign before a Notary Public. Print Name: _____________________________________ Title: ________________________ Authorized Signature:_________________________________________ Date:____________________ NOTARY PUBLIC USE ONLY: (State of ________________________, County of ____________________) SUBSCRIBED AND SWORN TO before me this ______________ day of ______________________________, 20______ By:__________________________________________________ SEAL Notary Public: ________________________________________ My Commission Expires:________________________________ ALCOHOL & GAMING DIVISION USE ONLY: Payment| Application Fee $_______________ Received on: _______________ Receipt No. __________________ Approved Disapproved, ________________________________________________________________ Processed By: __________________________________________________ Date: _________________________ Assigned Permit Number: _________________________ Approved Permit Sent on: _____________________ By: Email 1st class mail Fax Revised 5/24/16 American LegalNet, Inc. www.FormsWorkFlow.com