New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.5B - Request to Determine Employment or Reapplication Eligibility

1. Name, including maiden name and any aliases or nicknames and applicable dates of use;

2. Date of birth;

3. Current address;

4. Current employment;

5. A physical description;

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. Reason for submission;

8. Arrests, convictions, charges or offenses committed;

9. Reasons for the denial or revocation of any casino employee license or registration;

10. A written statement of the facts and circumstances which warrant the relief sought;

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

12. 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.

1. Letters of reference and supporting documentation; and

2. If the request is filed pursuant to 13:69A-8.11: