New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.3 - Personal History Disclosure Form 1

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Person
				History Disclosure Form (PHD-1) 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 along with applicable dates of usage;
2. Date and place of birth;
3. Physical description;
4. Current address and telephone number, and
				residence history for the past 10 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. Reason for filing the
				PHD-1;
8. Marital history and other
				family data;
9. Employment history,
				including any gaming-related employment, for the past 10 years;
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, approval or registration 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 jurisdictions, 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 in the past ten years; 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
				Division, 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 during the last ten year period as well as with regard to
				safe deposit boxes;
iii. Real
				estate interests held by the applicant or the applicant's spouse or dependent
				children in the past 10 years regardless of whether such interest was held
				under a recorded or unrecorded instrument;
iv. Any business in which the applicant has
				held an ownership interest for the past 20 years;
v. Copies of Federal and New Jersey tax
				returns and related information for the last five years;
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, in the past 20 years or in which the applicant served as an
				officer or director;
vii. 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 name and address holder of the obligation;
viii. Positions held or interest received in
				any estate or trust during the last 10-year period;
ix. Insurance claims in excess of $ 100,000
				by the applicant or the applicant's spouse or dependent children filed within
				the past 10-year period;
x. Loans
				in excess of $ 10,000 made or received by the applicant, the applicant's spouse
				or dependent children in the last 10-year period;
xi. During the last five-year period, any
				gifts in excess of $ 10,000, either individually or in the aggregate, given or
				received, whether tangible or intangible, by the applicant or the applicant's
				immediate family in any one-year period; and
xii. Referral or finder's fees in excess of $
				10,000 in the past 10 years.