New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.5C - Casino Employee License Conversion Application

1. Name, including change of name, if applicable, with a copy of appropriate documentation;

2. Date of birth;

3. Physical description;

4. Current address;

5. Current license number and expiration date;

6. Home and work telephone numbers;

7. 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;

8. Citizenship, and, if applicable, resident alien status, including any employment authorization with expiration date;

9. Employment history, including any gaming-related employment and any reprimands, suspensions, terminations or requests to leave;

10. 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 that has been suspended, revoked, or denied;

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

12. All governmental financial liens, lawsuits 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 to release any and all information pertaining to the applicant as requested by the Division.