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AGD Stamp New Mexico Regulation and Licensing Department | Alcohol and Gaming Division | Page 5 Revised 5/16 PO Box 25101 Santa Fe, NM 87504-5101 | Phone: (505) 476-4875 Fax: (505) 476-4595 AGD USE ONLY: Payment| Application Fee $______________ Received on: ______________ Receipt No. __________________ DESIGNATION OF RESIDENT AGENT $50.00 non-refundable fee Name of Corp./LLC/Partnership/Trust (print) ______________________________________________ Liquor License # ______________ D/B/A Name: ____________________________________________________________________________________________________ KNOW ALL MEN BY THESE PRESENT that the above-named Company hereby makes, constitutes and APPOINTS: (Print Appointee's Name)___________________________________________________________, to act as Resident Agent on behalf of the company and accept service of process for all purposes relating to the sales and service of the alcoholic beverages, including orders and notices of the Director and/or the Division. (Check one) Initial Resident Agent Adding another Resident Agent Replacing Resident Agent, remove: __________________________ Appointed and Submitted by an Authorized Officer of Corporation/ LLC/ Partnership/ Trust: Sign in the presence of a Notary Public. Signature: _____________________________________________________________ Title___________________________________ ACKNOWLEDGEMENT BY OFFICER APPOINTING AGENT NOTARY PUBLIC USE ONLY: (State of ___________________________, County of ________________________________) SUBSCRIBED & SWORN TO before me, this ____________ day of _____________________________, 20_______ By:____________________________________________ Notary Public: _______________________________________ My Commission Expires:____________________________ SEAL ACCEPTANCE OF APPOINTMENT BY RESIDENT AGENT I, (print name) ____________________________________________, accept the appointment as Resident Agent, and by accepting this appointment hereby Certify that I am a Resident of the State of New Mexico. I am also the Resident Agent for the following New Mexico Liquor License(s): ___________________, ___________________, __________________, _________________, _________________ Residence Address: ______________________________________________________________________________________________ City: ___________________________________ State: ____________________ Zip: ________________ Phone # _________________ Alcohol Server Permit # ____________________________________ Expires on: ______________________, Required to Attach Copy Sign in the presence of a Notary Public. Signature of Resident Agent: ______________________________________________________ Date: ___________________________ ACKNOWLEDGEMENT NOTARY PUBLIC USE ONLY: (State of ___________________________, County of ________________________________) SUBSCRIBED & SWORN TO before me, this ____________ day of _____________________________, 20_______ By:____________________________________________ Notary Public: _______________________________________ My Commission Expires:____________________________ SEAL FOR ALCOHOL AND GAMING DIVISION USE ONLY: Fingerprints submitted on: ________________ Cleared on: ____________ Approved Disapproved Signed by Director: _________________________________________________________ Date: _____________________ American LegalNet, Inc. www.FormsWorkFlow.com