New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.15A - Business Entity Disclosure Form-Ancillary Casino Service Industry Enterprise License

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Business
				Entity Disclosure Form-Ancillary Casino Service Industry Enterprise (BED-ACSI)
				shall be in a format prescribed by the Division and require the enterprise to
				provide the following information:
1. The
				current or former official and trade names used and the dates of use;
2. The current and former business addresses
				within the last 10-year period and dates of use;
3. The business telephone number;
4. The name, title, and telephone number of
				the contact person;
5. Whether the
				application is for initial licensure or retention of that license and, if
				retention, the license number and date of last submission;
6. If the license applicant is other than the
				enterprise filing the form, the reason for filing and the nature of the filing
				enterprise's relationship to the license applicant;
7. The business form and, as appropriate, a
				copy of the certificate of incorporation, charter, bylaws, partnership
				agreement and all amendments, trust agreement, or other documentation relating
				to the legal organization of the enterprise;
8. If a publicly traded corporation, the
				stock exchange its stock is traded on and its symbol;
9. The Federal Employer Identification
				Number;
10. A description of the
				present and any former business engaged in or intended to be engaged in by the
				enterprise and any parent, holding, intermediary, or subsidiary company within
				the past five years and similar information for former businesses for the past
				10 years;
11. A description of the
				nature, type, number of shares, terms, conditions, rights, and privileges of
				all classes of stock issued by the enterprise, if any, and the amount
				outstanding of each, or which the enterprise plans to issue;
12. The name, address, date of birth (if
				appropriate), class of non-voting stock, number, and percentage of shares held
				by each person or entity having a beneficial interest in any non-voting
				stock;
13. The name, home address,
				date of birth, current title or position, and if applicable, number of shares
				and class of stock and percentage of ownership for the following persons:
i. Each officer, director, or
				trustee;
ii. Each partner whether
				general, limited, or otherwise;
iii. The sole proprietor;
iv. Each natural person or entity that
				directly or indirectly holds any beneficial or ownership interest of five
				percent or more of the entity completing the form;
v. Each sales representative or other person
				who will regularly solicit business from a casino licensee;
vi. Each management person who supervises a
				regional or local office that employs sales or junket representatives or other
				persons who regularly solicit business from a casino hotel;
vii. Any other person not otherwise specified
				in (a)13i through vi above who has signed or will sign any agreement with a
				casino licensee;
viii. If a junket
				enterprise, in addition to (a)13iv above, each junket representative who will
				deal directly with casino licensees and their employees;
14. A flow chart that illustrates the
				ownership of any other enterprise that holds an interest in the filing
				enterprise;
15. The name, last
				known address, date of birth, position, dates the position was held, and reason
				for leaving for any former officers or directors who held such office during
				the preceding 10 years;
16. The
				annual compensation of each partner, officer, director, and trustee;
17. The name, home address, date of birth,
				position, length of time employed, and the amount of compensation of each
				person, other than the persons identified in (a)13 above, who is currently
				expected to receive annual compensation of more than $ 300,000;
18. A description of all bonus, profit
				sharing, pension, retirement, deferred compensation, or similar plans in
				existence or to be created by the enterprise;
19. If the enterprise is a partnership, a
				description of the interest held by each partner, whether limited or general,
				amount of initial investment, amount of additional contribution, amount and
				nature of any anticipated future investments, degree of control of each
				partner, percentage of ownership of each partner, and method of distributing
				profits to each partner;
20. A
				description of the nature, type, terms, covenants, and priorities of all
				outstanding debt and the name, address, and date of birth of each debt holder
				or security holder, type and class of debt instrument held, original debt
				amount, and current debt balance;
21. A description of the nature, type, terms,
				and conditions of all securities options;
22. The following information, for the last
				10 years, for each account held by a bank, savings and loan association, or
				other financial institution, whether foreign or domestic, in the name of the
				enterprise or its nominee, or which is otherwise under the direct or indirect
				control of the enterprise:
i. The name and
				address of the financial institution;
ii. The type of account;
iii. The account numbers; and
iv. The dates held;
23. The name and address of each company in
				which the enterprise holds stock, type of stock held, purchase price per share,
				number of shares held, and percentage of ownership indicating any holding of
				five percent or more of ownership held;
24. Information regarding any transaction
				during the past five years involving a change in the beneficial ownership of
				the enterprise's securities on the part of an officer or director who owned
				more than 10 percent of any class of equity security either directly or
				indirectly;
25. A description of
				any civil, criminal, administrative, and investigatory proceedings in any
				jurisdiction in which the enterprise or its subsidiaries have been involved as
				follows:
i. Any arrest, indictment, charge,
				or conviction for any criminal or disorderly persons offense;
ii. Any criminal proceeding in which the
				enterprise or its subsidiaries has been a party or has been named as an
				unindicted co-conspirator;
iii.
				Existing civil litigation if damages are reasonably expected to exceed $
				100,000, except for claims covered by insurance;
iv. Any judgment, order, consent decree, or
				consent order entered against the enterprise pertaining to a violation or
				alleged violation of the Federal antitrust, trade regulation, or securities
				laws or similar laws of any state, province, or country; and
v. Any judgment, order, consent decree, or
				consent order entered against the enterprise pertaining to a violation or
				alleged violation of any other State or Federal statute, regulation, or code
				that resulted in the imposition of a fine or penalty of $ 50,000 or
				more;
26. Within the
				last 10 years, for the enterprise and any holding or intermediary company,
				information regarding any judgments or petitions by or against it for
				bankruptcy or insolvency and any relief sought under any provision of the
				Federal Bankruptcy Act or any state insolvency law, and any receiver, fiscal
				agent, trustee, reorganization trustee, or similar officer appointed for the
				property or business of the enterprise or its parent, including any holding,
				intermediary, or subsidiary company;
27. Within the last 10 years, whether the
				enterprise has had any license or certificate denied, suspended, or revoked by
				any government agency in this State or any other jurisdiction, the nature of
				such license or certificate, the agency and its location, the date of such
				action, the disposition, the reasons therefor, and the facts related
				thereto;
28. Whether the enterprise
				has ever applied for a license, permit, or authorization to participate in any
				lawful gaming operation in this State or any other jurisdiction, the agency and
				its location, date of application, the activity, identifying number, and
				expiration date of each license, permit, or authorization;
29. Within the last 10 years, whether the
				enterprise or any director, officer, partner, employee, or person acting for or
				on behalf of the enterprise has made bribes or kickbacks to any employee,
				company, organization, or government official, foreign or domestic, to obtain
				favorable treatment or to obtain a competitive advantage;
30. Within the last 10 years, whether the
				enterprise has:
i. Donated or loaned its funds
				or property for the use or benefit of, or in opposing or supporting any
				government, political party, candidate, or committee, either foreign or
				domestic;
ii. Made any loans,
				donations, or disbursements to its directors, officers, partners, or employees
				for the purpose of making political contributions or reimbursing such
				individuals for political contributions, either foreign or domestic;
				or
iii. Maintained a bank account
				or other account, either foreign or domestic, not reflected on its books or
				records, or maintained any account in the name of a nominee for the
				enterprise;
31. The
				names and addresses of any current or former directors, officers, partners,
				employees, or third parties who would have knowledge or information concerning
				(a)29 and 30 above;
32. A copy of
				each of the following:
i. Annual reports for
				the past five years;
ii. If the
				enterprise is a corporation registered under the Securities Act of 1933 or the
				Securities Exchange Act of 1934, any annual reports prepared within the last
				five years on Form 10K pursuant to the Securities Exchange Act of
				1934;
iii. An audited financial
				statement for the last fiscal year, including, without limitation, an income
				statement, balance sheet, statement of sources, and application of funds, and
				all notes to such statements and related financial schedules;
iv. Copies of all annual financial
				statements, whether audited or unaudited, prepared in the last five fiscal
				years, any exceptions taken to such statements by an independent auditor, and
				the management response thereto;
v.
				Any current report prepared due to a change in control of the enterprise, an
				acquisition or disposition of assets, a bankruptcy or receivership proceeding,
				a change in the enterprise's certifying accountant, or any other material
				event, or, if the enterprise is registered with the SEC, a copy of the most
				recently filed Form 8K;
vi. The
				most recent Proxy or Information Statement filed pursuant to Section 14 of the
				Securities Exchange Act of 1934; and
vii. Registration Statements filed in the
				last five years pursuant to the Securities Act of 1933;
33. An organizational chart of the
				enterprise, including position descriptions and the name of the person holding
				each position;
34. Copies of all
				Internal Revenue Forms 1120 (corporate income tax return), all Internal Revenue
				Forms 1065 (partnership return), or all Internal Revenue Forms 1040 (personal
				return) filed for the last five years; and
35. A copy of a business registration
				certificate or other proof of valid business registration with the Division of
				Revenue in the New Jersey Department of the Treasury.