New Jersey Administrative Code › Title 19 - OTHER AGENCIES › NEW JERSEY SCHOOLS DEVELOPMENT AUTHORITY › Chapter 41A - APPLICATIONS FOR KEY EMPLOYEE LICENSE › Subchapter 7 - FORMS › Section 19:41A-7.3 - Personal History Disclosure Form 1B (Basic Key Form)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Personal History Disclosure Form
				  (PHD-1B) shall be in a format prescribed by the Commission and may require the
				  applicant to provide the following information:
1. Name, including any aliases or
				  nicknames;
2. Date of
				  birth;
3. Physical
				  description;
4. Current address and
				  residence history;
5. Social
				  Security number, which information is voluntarily provided in accordance with
				  section 7 of the Privacy Act,
				  5
				  U.S.C. §
												552 a;
6. Citizenship and, if applicable, resident
				  alien status, including any employment authorization;
7. Marital history and other family
				  data;
8. Telephone number at
				  current place of employment;
9.
				  Employment history, including any gaming-related employment;
10. Education and training;
11. Record of military service;
12. Licenses and other approvals held by or
				  applied for by the applicant or, where specified, the applicant's spouse, in
				  this State or any other jurisdiction, including:
i. Any license, permit, approval, or
				  registration required to participate in any lawful gambling operation in this
				  State or any jurisdiction;
ii. Any
				  denial, suspension, or revocation by a government agency in this State or any
				  other jurisdiction of a license, permit, or certification held by or applied
				  for by the applicant or the applicant's spouse; and
iii. Motor vehicle registrations and operator
				  licenses held by or applied for by the applicant or the applicant's spouse, and
				  any revocation or suspension thereof;
13. Civil, criminal, and investigatory
				  proceedings in any jurisdiction, as follows:
i. Arrests, charges, or offenses committed by
				  the applicant or any member of the applicant's immediate family;
ii. Any appearance before, investigation by,
				  or request to take a polygraph examination by any governmental agency, court,
				  committee, grand jury, or investigatory body; and
iii. Lawsuits to which the applicant was or
				  is a party; and
14.
				  Financial data, as follows:
i. All assets and
				  liabilities of the applicant, and the applicant'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,
				  credit card debt, and any other indebtedness, contingent liabilities,
				  securities, real estate interests, real estate mortgages and liens, life
				  insurance, pension funds, vehicles, and other assets;
ii. Bank accounts, including any right of
				  ownership in, control over or interest in any foreign bank account, and safe
				  deposit boxes;
iii. Real estate
				  interests held by the applicant or the applicant's spouse or dependent
				  children;
iv. Businesses
				  owned;
v. Copies of Federal and New
				  Jersey tax returns and related information;
vi. Judgments or petitions for bankruptcy or
				  insolvency concerning the applicant or any business entity in which the
				  applicant held a five percent or greater interest, other than a publicly traded
				  corporation, or in which the applicant served as an officer or
				  director;
vii. 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;
viii. Positions held or
				  interest received in any estate or trust;
ix. Insurance claims in excess of $ 100,000
				  by the applicant or the applicant's spouse or dependent children;
x. Loans in excess of $ 10,000 made or
				  received by the applicant, the applicant's spouse, or dependent
				  children;
xi. Gifts in excess of $
				  10,000 given or received by the applicant or the applicant's immediate family;
				  and
xii. Referral or finder's fees
				  in excess of $ 10,000.