New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.11B - Personal History Disclosure Form 2-Outside Directors of Holding and Intermediary Companies of Casino Service Industry Enterprises

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Personal
				History Disclosure Form 2 (or PHD-2) 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;
2. Date of
				birth;
3. Physical
				description;
4. Current address and
				telephone number, and residence history for the past five years;
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 and expiration date,
				country of which the applicant is a citizen, place of birth, port of entry to
				the United States, and name and address of sponsor(s) upon the applicant's
				arrival;
7. Marital
				history;
8. Employment history,
				including any gaming-related employment, for the past five years;
9. Education and training;
10. Record of military service;
11. Licenses and other approvals held by or
				applied for by the applicant in this State or any other jurisdiction,
				including:
i. Any license, permit, approval,
				or registration required to participate in any lawful gambling
				operation;
ii. Any denial,
				suspension, or revocation by a government agency of a license, permit, or
				certification; and
iii. Motor
				vehicle registrations and operator licenses and any revocation or suspension
				thereof;
12. Civil,
				criminal, and investigatory proceedings in any jurisdiction, as follows:
i. Arrests, charges, or offenses committed by
				the applicant;
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 in the past 10 years;
13. All governmental financial liens or
				judgments, including state tax liens, delinquent child support obligations,
				defaulted student loans, unemployment judgments, unpaid motor vehicle
				surcharges, welfare judgments, etc.
14. Financial data, as follows:
i. Any business in which the applicant has
				held an ownership interest for the past 10 years;
ii. Bank accounts and safe deposit
				boxes;
iii. Judgments or petitions
				for bankruptcy or insolvency concerning the applicant, including a copy of the
				bankruptcy petition and discharge, if granted, and any such judgment or
				petition concerning any business entity in which the applicant held a five
				percent or greater interest, other than a publicly traded corporation, in the
				past 20 years or in which the applicant served as an officer or director;
				and
iv. Any garnishment or
				attachment of wages, charging order, or voluntary wage execution, during the
				past 10-year period including the amount, court, nature of the obligation, and
				the holder of the obligation.