Form 21 "New Jersey Supplemental Form to the Multi-Jurisdictional Personal History Disclosure Form - Casino Qualifiers and Casino Key Employee Qualifiers" - New Jersey

What Is Form 21?

This is a legal form that was released by the New Jersey Department of Law and Public Safety - Office of The Attorney General - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 11, 2020;
  • The latest edition provided by the New Jersey Department of Law and Public Safety - Office of The Attorney General;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 21 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Law and Public Safety - Office of the Attorney General.

ADVERTISEMENT
ADVERTISEMENT

Download Form 21 "New Jersey Supplemental Form to the Multi-Jurisdictional Personal History Disclosure Form - Casino Qualifiers and Casino Key Employee Qualifiers" - New Jersey

Download PDF

Fill PDF online

Rate (4.6 / 5) 78 votes
STATE OF NEW JERSEY
Division of Gaming Enforcement
NEW JERSEY SUPPLEMENTAL FORM
TO THE MULTI-JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM -
Casino Qualifiers
Casino Key Employee Qualifiers
STATE OF NEW JERSEY
Division of Gaming Enforcement
NEW JERSEY SUPPLEMENTAL FORM
TO THE MULTI-JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM -
Casino Qualifiers
Casino Key Employee Qualifiers
New Jersey Supplemental Form
to the Multi-Jurisdictional
Personal History Disclosure Form
This form is a supplement to the MULTI-JURISDICTIONAL PERSONAL HISTORY DISCLOSURE
FORM. If you are using the Multi-Jurisdictional Personal History Disclosure Form to apply for
qualification in more than one jurisdiction, and one of those jurisdictions is New Jersey, you are required
to file this supplemental form as part of your New Jersey application. The other jurisdictions where you
are filing may also have supplemental forms, and it is your responsibility to obtain these forms and make
the appropriate filings. Copies of the forms used in New Jersey are available on the Internet at
http://www.nj.gov/oag/ge/forms.html
or you may request that the forms be mailed to you by calling
(609) 441-3846.
INSTRUCTIONS
I.
COMPLETING THIS FORM:
A.
You are to complete this form and a Multi-Jurisdictional Personal History Disclosure
Form if you are:
1.
A qualifier of a casino applicant or casino licensee, pursuant to N.J.S.A. 5:12-82b
or c and 85.1; or
2.
An applicant for a casino key employee license, pursuant to N.J.S.A. 5:12-89,
who is also a qualifier identified above; or
3.
Directed to do so by the Division of Gaming Enforcement (Division).
B.
Read each question carefully prior to answering. Answer every question completely. Do
not leave blank spaces. If a question does not apply to you, indicate “Does Not Apply” in
response to that question. If there is nothing to disclose in response to a particular
question, write “None” in response to that question. Failure to provide a response to
every question could result in the rejection of your application.
C.
All entries on this form, except initials and signatures, must be typed or printed in block
lettering using dark ink. If the application is not legible, it will not be accepted. Any
modification to the questions or the pre-printed information asked for in this form, will
result in the rejection of your application.
D.
If the space available is insufficient to respond to a question, you are to supply the
required information on an attachment page and clearly identify which question you are
answering.
E.
All attachments requested in this form are to be labeled with an exhibit number and
attached to the back of the form.
NJDGE 09/11/2020
Page 1 of 14 Pages
Initials / Date: ____/_______
II.
ESTABLISHING YOUR IDENTITY AND WORK AUTHORIZATION:
All applicants must come to the Division office listed below and establish their identity and
employment authorization:
New Jersey Division of Gaming Enforcement
Arcade Building
Tennessee Avenue and the Boardwalk
Atlantic City, NJ 08401
To establish your identity and employment authorization, in accordance with N.J.A.C. 13:69A-
7.2A, you must present the original document(s) listed below in A, B or C:
A.
A current and valid U.S. passport OR a Certificate of U.S. Citizenship OR a Certificate of
Naturalization OR a current and valid identification card issued by the USCIS containing a
photograph or fingerprints and identifying information such as name, date of birth, sex,
height, color of eyes, and address.
B.
If the items in II (A) above are not available, a certified copy of a U.S. birth certificate
issued by a state, county or municipal authority, with an official seal, must be presented
along with any one of the following authentic documents:
1.
A current and valid state-issued driver’s license that has a photograph and/or
identifying information;
2.
A current and valid identification card issued by the Department of Defense to
persons who serve in the U.S. military or their dependents that has a
photograph and/or identifying information;
3.
A current and valid student identification card containing a photograph, an
expiration date, the seal or logo of the issuing institution, and the signature of
the card holder;
4.
A current and valid identification card issued by a federal, state or local
government agency that has a photograph and/or identifying information; or
5.
A current and valid casino employee or casino key employee license, a casino
employee or casino key employee license that expired within the last five years,
or a valid casino service employee registration issued after February 2003.
C.
If the applicant is not a United States citizen, a current and valid foreign passport with
an employment authorization issued by the USCIS must be presented, along with any
one of the following authentic documents:
1.
A current and valid state-issued driver’s license that has a photograph and/or
identifying information;
NJDGE 09/11/2020
Page 2 of 14 Pages
Initials / Date: ____/_______
2.
A current and valid identification card issued by the Department of Defense to
persons who serve in the U.S. military or their dependents that has a
photograph and/or identifying information;
3.
A current and valid student identification card containing a photograph, an
expiration date, the seal or logo of the issuing institution, and the signature of
the card holder;
4.
A current and valid identification card issued by a federal, state or local
government agency that has a photograph and/or identifying information; or
5.
A current and valid casino employee or casino key employee license, a casino
employee or casino key employee license that expired within the last five years,
or a valid casino service employee registration issued after February 2003.
Note: Any person whose current legal name is different from the name on his or her certified
birth certificate (e.g., maiden name), must show legal proof of the name change. Legal proof
accepted is a certified marriage or civil union certificate, divorce decree or court order linking
the new name with the previous name. A divorce decree may be used as authority to resume
using a previous name only if it contains the new name and permits a return to use of the
previous name.
Call (609) 441-3846 if you have any questions about identification documents.
III.
BEFORE YOU SUBMIT THIS FORM TO THE DIVISION, BE SURE THAT:
A.
If you are also applying for a casino key employee license, you have established your
identity and work authorization in accordance with Section II and attached copies of
these documents to this form.
B.
All attachments required in this form and in the Multi-Jurisdictional Personal History
Disclosure Form are labeled with an exhibit number and included in both the original,
the photocopies and the computer disk filed with the Division.
C.
The Statement of Truth form in the Multi-Jurisdictional Personal History Disclosure Form
and the Release Authorization form attached to this New Jersey Supplement are
notarized on the original application.
D.
Every question has been answered completely.
E.
You initial and date each page of this form in the spaces provided.
F.
You retain a completed copy of this form for your own records.
NJDGE 09/11/2020
Page 3 of 14 Pages
Initials / Date: ____/_______
IV.
FILING THIS FORM WITH THE DIVISION:
A.
Submit this form and the Multi-Jurisdictional Personal History Disclosure Form and all
attachments as an original, two photocopies and a computer disk. If the photocopies of
these forms are not clear, the application will not be accepted.
B.
The fees relating to individual qualification/casino key employee licensure are as set
forth in N.J.A.C. 13:69A-9.1, et seq.
C.
You will be required to be fingerprinted in connection with the filing of this application,
N.J.S.A. 5:12-80f. To be fingerprinted, you may make an appointment with the Division’s
Identification Unit, which is located in the Arcade Building, Tennessee Avenue and the
Boardwalk, Atlantic City, New Jersey. Call for an appointment at (609) 441-3050. There
is no charge for fingerprinting. When you arrive for your fingerprinting appointment,
you must present the identification documents listed in Section II to establish your
identity or you will not be fingerprinted. If you are unable to come to Atlantic City to
be fingerprinted, call the Division at (609) 441-3015 and request the requisite fingerprint
cards be sent to you so you can be fingerprinted at your local police department.
D.
Once the application is accepted, it becomes the property of the Division and may not
be withdrawn without the permission of the Division.
V.
IMPORTANT NOTICES
A.
Should you be unable to fully understand this form or any other form, in English, it is
your responsibility to acquire adequate means of translation.
B.
All notices regarding your application will be sent to the address which you provide on
this form. You must immediately notify the Division of any change of address.
C.
Pursuant to Section 86b of the Casino Control Act, failure to answer any question
completely and truthfully will result in denial of your license application.
D.
Pursuant to Section 79a(6) of the Casino Control Act, any person who applies for and
obtains a license from the Division or is required to qualify, is subject to warrantless
searches when present in a licensed casino facility.
E.
Pursuant to Section 74.1 of the Casino Control Act, information supplied to the
Commission and Division or otherwise obtained by either of them, is confidential and
shall not be revealed, except in the course of the necessary administration of the Casino
Control Act, or upon the lawful order of a court of competent jurisdiction or, with the
approval of the Attorney General, to a duly-authorized law enforcement agency.
Nevertheless, pursuant to Section 80b of the Casino Control Act, an applicant, licensee
or person required to qualify, waives any liability of the State of New Jersey and its
instrumentalities and agents, for any damages resulting from any disclosure or
publication in any manner, other than a willfully unlawful disclosure or publication.
NJDGE 09/11/2020
Page 4 of 14 Pages
Initials / Date: ____/_______