New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.5 - Personal History Disclosure Form 3 - Casino Employee Registration

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

2. Date of birth;

3. Physical description;

4. Current address and residence history for the past year;

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. Last three jobs, and any gaming-related employment during the last 10 years;

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

10. Any license, permit, approval or registration held by the applicant to work in the gaming industry suspended, revoked or denied or had any disciplinary action taken in New Jersey or any other jurisdiction;

11. Arrests, charges or offenses committed by the applicant; and

12. 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.

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

2. 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 applicant as requested by the Division.