N.J. Admin. Code § 19:41A-7.3 - Personal History Disclosure Form 1B (Basic Key Form)

(a) A Personal History Disclosure Form (PHD-1B) shall be in a format prescribed by the Commission and may require the applicant to provide the following information:

1. Name, including any aliases or nicknames;

2. Date of birth;

3. Physical description;

4. Current address and residence history;

5. Social Security number, which information is voluntarily provided in accordance with section 7 of the Privacy Act, 5 U.S.C. § 552 a;

6. Citizenship and, if applicable, resident alien status, including any employment authorization;

7. Marital history and other family data;

8. Telephone number at current place of employment;

9. Employment history, including any gaming-related employment;

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, or certification 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 jurisdiction, 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; 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 Commission, 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, 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 and New Jersey tax returns and related information;

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, or in which the applicant served as an officer or director;

vii. 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;

viii. Positions held or interest received in any estate or trust;

ix. Insurance claims in excess of $ 100,000 by the applicant or the applicant's spouse or dependent children;

x. Loans in excess of $ 10,000 made or received by the applicant, the applicant's spouse, or dependent children;

xi. Gifts in excess of $ 10,000 given or received by the applicant or the applicant's immediate family; and

xii. Referral or finder's fees in excess of $ 10,000.

(b) In addition to the information in (a) above, a completed PHD-1B shall include the following:

1. A signed, dated, and notarized certification of truth;

2. A signed, dated, and notarized Release Authorization which shall direct all courts, probation departments, selective service boards, employers, educational institutions, financial and other institutions, and all governmental agencies to release any and all information pertaining to the applicant as requested by the Commission or the Division; and

3. The name, address, occupation, and telephone number of persons who can attest to the applicant's good character and reputation.

Notes

N.J. Admin. Code § 19:41A-7.3

Adopted by 47 N.J.R. 1653(a), effective 7/6/2015