New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.14 - Labor Organization Individual Disclosure Form

1. Name, including maiden name and any aliases or nicknames;

2. Title or position with the labor organization;

3. Date and place of birth;

4. Physical description including photograph taken within the past 12 months and name printed across the front bottom border;

5. Current address and home telephone number and residence history for the past year;

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. Citizenship and, if applicable, information concerning resident alien status;

8. Full name of the labor organization represented;

9. Telephone number at current place of employment;

10. Employment history:

11. Licenses or other approvals held or applied for which are required to participate in any lawful gambling operation in this State or any jurisdiction;

12. Civil, criminal and investigatory proceedings in any jurisdiction as follows:

13. Financial data, including information concerning any financial interests held in a casino hotel, casino, casino simulcasting facility or casino licensee.

1. The name, address, occupation and phone number of references;

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

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, Federal, state and local, both foreign and domestic, to release any and all information pertaining to the officer, agent or principal employee as requested by the Division; and

4. A waiver of liability as to the State and its instrumentalities and agents for any damages resulting to the officer, agent or principal employee from any disclosure or publication of information acquired during the investigation process, in accordance with N.J.S.A. 5:12-80b.