New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.2 - Multi-Jurisdictional Personal History Disclosure Form

i. Any professional or occupational license held by or applied for by the applicant or the applicant's spouse;

ii. 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;

iii. Possession or ownership of any pistol or firearm, or any application for any firearm permit, firearm dealer's license, or permit to carry a pistol or firearm;

iv. Any license, permit, approval or registration required to participate in any lawful gambling operation in this State or any jurisdiction held by or applied for by the applicant; and

v. Any denial, suspension or revocation by a governmental agency of a license, permit or certification held by or applied for by the applicant or the applicant's spouse, or any entity in which the applicant or the applicant's spouse was a director, officer, partner or an owner of a five percent or greater interest;

i. Arrests, charges or offenses committed by the applicant or any member of the applicant's immediate family;

ii. Any instance where the applicant has been named as an unindicted party or co-conspirator in a criminal proceeding or held as a material witness;

iii. Any appearance before, investigation by or request to take a polygraph examination by any governmental agency, court, committee, grand jury or investigatory body, and any refusal to comply with a request to do so;

iv. Any pardons, dismissals, suspensions or deferrals of any criminal investigation, prosecution, or conviction;

v. Lawsuits to which the applicant was or is a party;

vi. Any citation or charge for a violation of a statute, regulation or code of any jurisdiction, other than a criminal, disorderly persons, petty disorderly persons or motor vehicle violation; and

vii. Any use, distribution, or possession of any narcotic, hallucinogenic, drug, barbiturate, amphetamine or other substance listed in Schedule I through V of 2C:35-5 et seq. other than pursuant to a valid prescription issued by a licensed physician;

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 Division, including cash, bank accounts, notes payable and receivable, real estate and income taxes payable, loans, accounts payable 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 tax returns and related information;

vi. Judgments or petitions for bankruptcy, insolvency or liquidation 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 business entity in which the applicant was an owner, director or officer which has been placed under some form of governmental administration or monitoring;

viii. 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;

ix. Any repossessions of real or personal property;

x. Any guarantees, co-signatures or insuring of payments of financial obligations of any persons or business entities;

xi. Status as executor, administrator or fiduciary of an estate;

xii. Life insurance policies on the applicant's life which name someone other than the applicant's family as a beneficiary;

xiii. Positions held, assets held, or interest received in any estate or trust;

xiv. Whether the applicant has ever been bonded for any purpose or been denied any type of bond, including the nature of the bond and if applicable, the reason for denial;

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

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

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

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

xix. Brokerage or margin accounts with any securities or commodities dealer;

xx. Currency exchanges in an amount greater than $ 10,000;

xxi. Information regarding any instance where the applicant or any entity in which the applicant was a director, officer or holder of a five percent or greater interest has traded in foreign currencies or in a foreign commodities exchange, sold or purchased discounted promissory notes or other commercial paper, or been a party to any leasing arrangements in excess of $ 50,000; and

xxii. Information regarding any ownership interest or financial investment by the applicant in any entity which holds or is an applicant for a license issued by the Division or the Commission, or in any gambling venture which does not require licensure by the Division or the Commission, including persons providing or reasonably anticipated to provide the applicant with support in the financing of such investment or interest; the extent and nature of the applicant's involvement in the management and operation of the entity; whether the applicant has or has agreed to assign, pledge or hypothecate such interest or investment, the nature and terms of any such transaction and a copy of any such agreement.