New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.2B - Ancillary Casino Service Industry Enterprise License-Personal History Disclosure Form

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

ii. 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;

iii. 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

iv. 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. Made or been charged with (either itself or through third parties acting for it) bribes or kickbacks to any government official, domestic or foreign, to obtain favorable treatment or to any company, employee, or organization to obtain a competitive advantage;

ii. Held a foreign bank account or has had authority to control disbursements from a foreign bank account;

iii. Maintained a bank account or other account, whether domestic or foreign, which is not reflected on the books or records of the business or which is in a name other than the name of the business;

iv. Donated, loaned, or used funds or property for the use or benefit of or in opposing any government, political party, candidate, or committee either domestic or foreign;

v. Compensated any of its directors, officers, or employees for time and expenses incurred in performing services for the benefit of or in opposing any government or political party domestic or foreign; or

vi. Made any loans, donations, or other disbursements to its directors, officers, or employees for the purpose of making political contributions or reimbursing such individuals for political contributions whether domestic or foreign;

i. All assets and liabilities of the applicant, 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, and other assets;

ii. Bank accounts, including any right of ownership in, control over, or interest in any foreign bank accounts, and safe deposit boxes;

iii. Real estate interests held by the applicant, the applicant's spouse, or dependent children;

iv. Businesses owned;

v. Copies of Federal and foreign tax returns and related information for the last five years;

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

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

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

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

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

xx. Information regarding any ownership interest or financial investment by the applicant in any entity that holds or is an applicant for a license issued by the Division or the Commission, or in any gambling venture that 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.