New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.11A - Casino Service Industry Enterprise and Ancillary Casino Service Industry Enterprise-Qualifier Resubmission Disclosure Form

1. Name;

2. Address, telephone number and e-mail address;

3. Position held with the casino service industry enterprise;

4. Date and place of birth;

5. Physical characteristics;

6. Arrests, charges, convictions or other offenses committed by the qualifier since the date on which the qualifier last filed a QRDF;

7. Citizenship and, if applicable, resident alien status; and

8. Any and all personal and financial information the Division requires to demonstrate the licensee continues to meet the requirements of N.J.S.A. 5:12-92a and b.

1. Copies of Federal and New Jersey tax returns and related information;

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

3. 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 government agencies, Federal, state and local, foreign or domestic, to release any and all information pertaining to the qualifier as requested by the Division.