New Jersey Administrative Code
Title 13 - LAW AND PUBLIC SAFETY
Chapter 69A - APPLICATIONS
Subchapter 5 - FORMS
Section 13:69A-5.9 - Qualifier Disclosure Form-Casino Hotel Alcoholic Beverage Enterprise

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

2. Current telephone number, home and work addresses and residence history for the past five years;

3. Position held with the CHAB Enterprise license applicant or holding company;

4. Date and place of birth;

5. Physical characteristics;

6. Last three jobs, including an indication if gaming was conducted on the premises;

7. Information regarding any license, permit, approval, registration or other authorization to participate in a lawful gambling operation held by or applied for by the applicant in this State or any other jurisdiction; and

8. Arrests, charges or offenses committed by the applicant.

1. An original photograph of the applicant taken within the previous 12 months with the name printed along the bottom border of the front;

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

3. 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.