New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.11B - Personal History Disclosure Form 2-Outside Directors of Holding and Intermediary Companies of Casino Service Industry Enterprises

Universal Citation: NJ Admin Code 13:69A-5.11B

Current through Register Vol. 56, No. 18, September 16, 2024

(a) A Personal History Disclosure Form 2 (or PHD-2) 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;

2. Date of birth;

3. Physical description;

4. Current address and telephone number, and residence history for the past five years;

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, resident alien status, including any employment authorization and expiration date, country of which the applicant is a citizen, place of birth, port of entry to the United States, and name and address of sponsor(s) upon the applicant's arrival;

7. Marital history;

8. Employment history, including any gaming-related employment, for the past five years;

9. Education and training;

10. Record of military service;

11. Licenses and other approvals held by or applied for by the applicant in this State or any other jurisdiction, including:
i. Any license, permit, approval, or registration required to participate in any lawful gambling operation;

ii. Any denial, suspension, or revocation by a government agency of a license, permit, or certification; and

iii. Motor vehicle registrations and operator licenses and any revocation or suspension thereof;

12. Civil, criminal, and investigatory proceedings in any jurisdiction, as follows:
i. Arrests, charges, or offenses committed by the applicant;

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 in the past 10 years;

13. All governmental financial liens or judgments, including state tax liens, delinquent child support obligations, defaulted student loans, unemployment judgments, unpaid motor vehicle surcharges, welfare judgments, etc.

14. Financial data, as follows:
i. Any business in which the applicant has held an ownership interest for the past 10 years;

ii. Bank accounts and safe deposit boxes;

iii. Judgments or petitions for bankruptcy or insolvency concerning the applicant, including a copy of the bankruptcy petition and discharge, if granted, and any such judgment or petition concerning any business entity in which the applicant held a five percent or greater interest, other than a publicly traded corporation, in the past 20 years or in which the applicant served as an officer or director; and

iv. Any garnishment or attachment of wages, charging order, or voluntary wage execution, during the past 10-year period including the amount, court, nature of the obligation, and the holder of the obligation.

(b) In addition to the information in (a) above, a completed PHD-2 may include the following:

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

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 governmental agencies to release any and all information pertaining to the applicant as requested by the Division.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.