N.J. Admin. Code § 13:69A-5.10 - New Jersey Supplemental Form-Casino Service Industry Enterprise Qualifiers

(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.

Notes

N.J. Admin. Code § 13:69A-5.10

Amended by 50 N.J.R. 601(b), effective 1/16/2018