New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.10 - New Jersey Supplemental Form-Casino Service Industry Enterprise Qualifiers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A New Jersey Supplemental Form shall be
				in a format prescribed by the Division and may 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 addresses; mailing and home, if
				different;
5. Home and work
				telephone numbers;
6. 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;
7. The casino licensee or applicant, casino
				service industry enterprise licensee or applicant, or holding company, as
				applicable, with which the applicant is affiliated, the address of the entity,
				the title or position of the applicant in such entity, and the nature of the
				applicant's position with or interest in such entity;
8. Citizenship and, if applicable, petition
				number, certification number and date and court that granted naturalization, or
				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;
9. Any
				interest in any business entity which is licensed by the Division or is an
				applicant therefore;
10. Within the
				last 10 years, whether 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 making bribes or
				kickbacks, either itself or through third parties acting for it, 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, 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 for the purpose of
				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 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 either domestic or foreign;
11. Copies of Federal and foreign
				tax returns with appropriate schedules and related information for the last
				three years. If the applicant and the applicant's spouse filed separate tax
				returns for any year in the last five years, also attach a copy of the
				applicant's spouse's tax returns; and
12. A signed, dated and notarized Release
				Authorization which shall direct all courts, probation departments, selective
				service boards, employers, educational institutions, banks, financial and other
				institutions and all governmental agencies Federal, state and local, both
				foreign and domestic, to release any and all information pertaining to the
				applicant as requested by the Division.