New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.2 - Multi-Jurisdictional Personal History Disclosure Form

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A
				Multi-Jurisdictional Personal History Disclosure Form (PHD-MJ) 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;
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,
				information regarding resident alien status, including information regarding
				passports;
7. Marital history,
				dependents and other family data;
8. The casino licensee or applicant, 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. Telephone number at the current place of
				employment;
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. Current memberships in any social, labor
				or fraternal union, club or organization;
16. 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. 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;
iii. 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;
iv. 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
v. 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;
17. Any interest in or employment presently
				or previously held by the applicant with an entity which 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;
18. 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;
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, 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 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 tax returns and related
				information;
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 which 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 which 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. Insurance claims in excess of $ 100,000
				by the applicant or the applicant's spouse or dependent children;
xvi. Referral or finder's fees in excess of $
				10,000;
xvii. Loans in excess of $
				10,000 made or received by the applicant, the applicant's spouse or dependent
				children;
xviii. Gifts in excess of
				$ 10,000 given or received by the applicant or the applicant's immediate
				family;
xix. Brokerage or margin
				accounts with any securities or commodities dealer;
xx. Currency exchanges in an amount greater
				than $ 10,000;
xxi. Information
				regarding any instance where the applicant or any entity in which the applicant
				was a director, officer or holder of a five percent or greater interest has
				traded in foreign currencies or in a foreign commodities exchange, sold or
				purchased discounted promissory notes or other commercial paper, or been a
				party to any leasing arrangements in excess of $ 50,000; and
xxii. Information regarding any ownership
				interest or financial investment by the applicant in any entity which holds or
				is an applicant for a license issued by the Division or the Commission, or in
				any gambling venture which 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.