Code of Massachusetts Regulations › 205 CMR - MASSACHUSETTS GAMING COMMISSION › Title 205 CMR 111.00 - Phase 1 Application Requirements › Section 111.03 - Multi-jurisdictional Personal History Disclosure Form

Current through Register 1525, July 5, 2024
(1) A PHD-MA shall be submitted by each
			 category 1 and category 2 qualifier and shall be in a format prescribed by the
			 commission and may require the qualifier to provide the following information
			 and such additional information as the commission may, in its discretion,
			 determine:
(a) Name, including maiden name
			 and any aliases or nicknames and applicable dates of use;
(b) Date of birth;
(c) Physical description;
(d) Current address and residence
			 history;
(e) Social Security
			 Number, which information is voluntarily provided in accordance with
			 5 U.S.C. §
										552a;
(f) Citizenship and, if applicable,
			 information regarding resident alien status, including information regarding
			 passports;
(g) Marital history,
			 spouse, dependents and other family data;
(h) The gaming licensee or qualifier, gaming
			 vendor licensee or qualifier or holding company, as applicable, with which the
			 qualifier is affiliated, and the nature of the qualifier's position with or
			 interest in such entity;
(i)
			 Telephone number at the current place of employment;
(j) Employment history of the qualifier and
			 qualifier's immediate family;
(k)
			 Education and training;
(l) Record
			 of military service;
(m) Government
			 positions and offices presently or previously held, and the offices,
			 trusteeships, directorships or fiduciary positions presently or previously held
			 with any business entity;
(n)
			 Trusteeships or other fiduciary positions held by the qualifier and the
			 qualifier's spouse, and any denial or suspension of, or removal from, such
			 positions;
(o) Current memberships
			 in any social, labor or fraternal union, club or organization;
(p) Licenses and other approvals held by or
			 applied for by the qualifier or, where specified, the qualifier's spouse, in
			 the Commonwealth of Massachusetts or any other jurisdiction, as follows:
1. Any professional or occupational license
			 held by or applied for the by the qualifier or the qualifier's
			 spouse;
2. Motor vehicle
			 registrations and operator licenses held by or applied for the by the qualifier
			 or the qualifier's spouse, and any revocation or suspension thereof;
3. Possession or ownership of any pistol or
			 firearm, or any application for any firearm permit, firearm dealer's license,
			 or permit to carry a pistol or firearm;
4. Any license, permit, approval or
			 registration required to participate in any lawful gambling operation in the
			 Commonwealth of Massachusetts or any jurisdiction held by or applied for by the
			 qualifier; and
5. Any denial,
			 suspension or revocation by a government agency of a license, permit or
			 certification held by or applied for by the qualifier or the qualifier's
			 spouse, or any entity in which the qualifier or the qualifier's spouse was a
			 director, officer, partner or any owner of a 5% or greater interest;
(q) Any interest in or employment
			 presently or previously held by the qualifier with any entity which has applied
			 for a permit, license, certificate or qualification in connection with any
			 lawful gambling or alcoholic beverage operation in the Commonwealth of
			 Massachusetts or any other jurisdiction; and any current employment or other
			 association by the qualifier's family with the gambling or alcoholic beverage
			 industries in the Commonwealth of Massachusetts or any other
			 jurisdiction;
(r) Civil, criminal
			 and investigatory proceedings in any jurisdiction, as follows:
1. Arrests, charges or offenses committed by
			 the qualifier or any member of the qualifier's immediate family;
2. Any instance where the qualifier has been
			 named as an unindicted party or co-conspirator in a criminal proceeding or held
			 as a material witness;
3. Any
			 appearance before, investigation by or request to take a polygraph examination
			 by any governmental agency, court, committee, grand jury or investigatory body,
			 and any refusal to comply with a request to do so;
4. Any pardons, dismissals, suspensions or
			 deferrals of any criminal investigation, prosecution, or conviction;
5. Lawsuits to which the qualifier was or is
			 a party;
6. Any citation or charge
			 for a violation of a statute, regulation or code of any jurisdiction, other
			 than a criminal disorderly persons, petty disorderly persons or motor vehicle
			 violation; and
7. Any use,
			 distribution, or possession of any narcotic, hallucinogenic, drug, barbiturate,
			 amphetamine or other substance listed in M.G.L. c. 94C other than pursuant to a
			 valid prescription issued by a licensed physician;
(s) Any exclusion or barring from any casino,
			 gaming establishment or gambling/gaming related entity in any jurisdiction;
			 and
(t) Financial data, as follows:
1. All assets and liability of the qualifier,
			 and the qualifier's spouse and dependent children as indicated on the net worth
			 statement and supporting schedules in a format prescribed by the commission,
			 including cash, bank accounts, notes payable and receivable, real estate and
			 income taxes payable, loans, accounts payable and any other indebtedness,
			 contingent liabilities, securities, real estate interests, real estate
			 mortgages and liens, life insurance, pension funds, vehicles and other
			 assets;
2. Bank accounts, including
			 any right of ownership in, control over or interest in any foreign bank
			 account, and safe deposit boxes;
3.
			 Real estate interests held by the qualifier or the qualifier's spouse or
			 dependent children;
4. Businesses
			 owned;
5. Copies of Federal tax
			 returns and related information;
6.
			 Judgments or petitions for bankruptcy, insolvency or liquidation concerning the
			 qualifier or any business entity in which the qualifier held a 5% or greater
			 interest, other than a publicly traded corporation, or in which the qualifier
			 served as an officer or director;
7. Any business entity in which the qualifier
			 was an owner, director or officer which has been placed under some form of
			 governmental administration or monitoring;
8. Any garnishment or attachment of wages,
			 charging order or voluntary wage execution, including the amount, court, nature
			 of the obligation and the holder of the obligation;
9. Any repossessions of real or personal
			 property;
10. Any guarantees,
			 co-signatures or insuring of payments of financial obligations of any persons
			 or business entities;
11. Status as
			 executor, administrator or fiduciary of any estate;
12. Life insurance policies on the
			 qualifier's life which name someone other than the qualifier's family as a
			 beneficiary;
13. Positions held,
			 assets held, or interest received in any estate or trust;
14. Whether the qualifier has ever been
			 bonded for any purpose or been denied any type of bond, including the nature of
			 the bond and if applicable, the reason for denial;
15. Insurance claims in excess of $100,000.00
			 by the qualifier or the qualifier's spouse or dependent children;
16. Referral or finder's fees in excess of
			 $10,000.00;
17. Loans in excess of
			 $10,000.00 made or received by the qualifier, the qualifier's spouse or
			 dependent children;
18. Gifts in
			 excess of $10,000.00 given or received by the qualifier or the qualifier's
			 immediate family;
19. Brokerage or
			 margin accounts with any securities or commodities dealer;
20. Currency exchanges in an amount greater
			 than $10,000.00;
21. Information
			 regarding any instance where the qualifier or any entity in which the qualifier
			 was a director, officer or holder of a five percent or greater interest has
			 traded in foreign currencies or in a foreign commodities exchange, sold or
			 purchased discounted promissory notes or other commercial paper, or been a
			 party to any leasing arrangements in excess of $50,000.00; and
22. Information regarding any ownership
			 interest or financial investment by the qualifier in any entity which holds or
			 is an applicant for a license issued by the commission, or in any gambling
			 venture which does not require licensure by the commission, including persons
			 providing or reasonably anticipated to provide the qualifier with support in
			 the financing of such investment or interest; the extent and nature of the
			 qualifier's involvement in the management and operation of the entity; whether
			 the qualifier has or has agreed to assign, pledge or hypothecate such interest
			 or investment, the nature and terms of any such transaction and a copy of any
			 such agreement.