New Jersey Administrative Code › Title 13 - LAW AND PUBLIC SAFETY › Chapter 69A - APPLICATIONS › Subchapter 5 - FORMS › Section 13:69A-5.2A - New Jersey Supplemental Form-Casino Qualifier

Current through Register Vol. 56, No. 14, July 15, 2024
(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, and the nature
				of the applicant's position with or interest in such entity;
8. 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;
9. Any interest in any
				business entity which is licensed by the Division or Commission or is an
				applicant therefore;
10. 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;
11. Copies of Federal and foreign
				tax returns and related information for the last five years; 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.