New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.2B - Ancillary Casino Service Industry Enterprise License-Personal History Disclosure Form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An Ancillary Casino Service Industry
				Enterprise License Personal History Disclosure Form (ACSI-PHD) shall be in a
				format prescribed by the Division and require the applicant to provide the
				following information:
1. Name, including
				maiden name, and any aliases or nicknames and applicable dates of
				use;
2. Date of birth;
3. Physical description, including a color
				photograph taken within the past six months;
4. Current address and residence
				history;
5. Social Security number,
				or the reason why the applicant does not have that number, which information
				shall be utilized solely for tax administration as provided under
42 U.S.C.
				§
												405
(c)(2)(C)(i) and
N.J.S.A. 54:50-25
and for
				child support enforcement as provided under
42
				U.S.C. §
												666
(a)(13) and
N.J.S.A.
				2A:17-56
.60;
6. Citizenship and, if applicable, resident
				alien status, including any employment authorization with expiration date,
				country of which the applicant is a citizen, place of birth, port of entry to
				the United States, and name and addresses of sponsor(s) upon the applicant's
				arrival;
7. Marital history,
				dependents, and other family data;
8. The ancillary casino service industry
				enterprise licensee or applicant or holding company, as applicable, with which
				the applicant is affiliated, and the nature of the applicant's position with,
				or interest in, such entity;
9.
				Current home and work telephone numbers;
10. Employment history of the applicant and
				the applicant's immediate family;
11. Education and training;
12. Record of military service;
13. Government positions and offices
				presently or previously held, and the offices, trusteeships, directorships, or
				fiduciary positions presently or previously held with any business
				entity;
14. Trusteeships or other
				fiduciary positions held by the applicant and the applicant's spouse, and any
				denial or suspension of, or removal from, such positions;
15. 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, as follows:
i. Any professional or occupational license
				held by or applied for by the applicant or the applicant's spouse;
ii. 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;
iii. Any license, permit, approval, or
				registration required to participate in any lawful gambling operation in this
				State or any jurisdiction held by or applied for by the applicant;
				and
iv. Any denial, suspension, or
				revocation by a governmental agency of a license, permit, or certification held
				by or applied for by the applicant or the applicant's spouse, or any entity in
				which the applicant or the applicant's spouse was a director, officer, partner,
				or an owner of a five percent or greater interest;
16. Any interest in or employment presently
				or previously held by the applicant with an entity that has applied for a
				permit, license, certificate, or qualification in connection with any lawful
				gambling or alcoholic beverage operation in this State or any other
				jurisdiction and any current employment or other association by the applicant's
				family with the gambling or alcoholic beverage industries in this State or any
				other jurisdiction;
17. 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 instance where the applicant has been
				named as an unindicted party or co-conspirator in a criminal proceeding or held
				as a material witness;
iii. 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;
iv. Any pardons, dismissals, suspensions, or
				deferrals of any criminal investigation, prosecution, or conviction;
v. Lawsuits to which the applicant was or is
				a party;
vi. 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
vii. Any use,
				distribution, or possession of any narcotic, hallucinogenic, drug, barbiturate,
				amphetamine, or other substance listed in Schedule I through V of
				2C:35-5 et seq. other than
				pursuant to a valid prescription issued by a licensed physician;
18. Whether during the last
				10-year period any entity in which the applicant has been a director, officer,
				principal employee, or a holder of five percent or more interest has:
i. Made or been charged with (either itself
				or through third parties acting for it) bribes or kickbacks to any government
				official, domestic or foreign, to obtain favorable treatment or to any company,
				employee, or organization to obtain a competitive advantage;
ii. Held a foreign bank account or has had
				authority to control disbursements from a foreign bank account;
iii. Maintained a bank account or other
				account, whether domestic or foreign, which is not reflected on the books or
				records of the business or which is in a name other than the name of the
				business;
iv. Donated, loaned, or
				used funds or property for the use or benefit of or in opposing any government,
				political party, candidate, or committee either domestic or foreign;
v. Compensated any of its directors,
				officers, or employees for time and expenses incurred in performing services
				for the benefit of or in opposing any government or political party domestic or
				foreign; or
vi. Made any loans,
				donations, or other disbursements to its directors, officers, or employees for
				the purpose of making political contributions or reimbursing such individuals
				for political contributions whether domestic or foreign;
19. Any exclusion or barring from any casino
				or gambling/gaming related entity in any jurisdiction; and
20. Financial data, as follows:
i. All assets and liabilities of the
				applicant, the applicant's spouse, and dependent children as indicated on the
				net worth statement and supporting schedules in a format prescribed by the
				Division, 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, and other
				assets;
ii. Bank accounts,
				including any right of ownership in, control over, or interest in any foreign
				bank accounts, and safe deposit boxes;
iii. Real estate interests held by the
				applicant, the applicant's spouse, or dependent children;
iv. Businesses owned;
v. Copies of Federal and foreign tax returns
				and related information for the last five years;
vi. Judgments or petitions for bankruptcy,
				insolvency, or liquidation 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 business entity
				in which the applicant was an owner, director, or officer that has been placed
				under some form of governmental administration or monitoring;
viii. 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;
ix. Any repossessions of real or personal
				property;
x. Any guarantees,
				co-signatures, or insuring of payments of financial obligations of any persons
				or business entities;
xi. Status as
				executor, administrator, or fiduciary of an estate;
xii. Life insurance policies on the
				applicant's life that name someone other than the applicant's family as a
				beneficiary;
xiii. Positions held,
				assets held, or interest received in any estate or trust;
xiv. Whether the applicant 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;
xv. Referral or finder's fees in excess of $
				10,000;
xvi. Loans in excess of $
				10,000 made or received by the applicant, the applicant's spouse, or dependent
				children;
xvii. Gifts in excess of
				$ 10,000 given or received by the applicant or the applicant's immediate
				family;
xviii. Brokerage or margin
				accounts with any securities or commodities dealer;
xix. Currency exchanges in an amount greater
				than $ 10,000; and
xx. Information
				regarding any ownership interest or financial investment by the applicant in
				any entity that holds or is an applicant for a license issued by the Division
				or the Commission, or in any gambling venture that does not require licensure
				by the Division or the Commission, including persons providing or reasonably
				anticipated to provide the applicant with support in the financing of such
				investment or interest; the extent and nature of the applicant's involvement in
				the management and operation of the entity; whether the applicant 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.