Form 33 "New Jersey Supplemental Form to the Multi-Jurisdictional Personal History Disclosure Form - Casino Service Industry Enterprise Qualifiers" - New Jersey

What Is Form 33?

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 33 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.

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Download Form 33 "New Jersey Supplemental Form to the Multi-Jurisdictional Personal History Disclosure Form - Casino Service Industry Enterprise Qualifiers" - New Jersey

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STATE OF NEW JERSEY
Division of Gaming Enforcement
NEW JERSEY SUPPLEMENTAL FORM
TO THE MULTI-JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM
Casino Service Industry Enterprise Qualifiers
STATE OF NEW JERSEY
Division of Gaming Enforcement
NEW JERSEY SUPPLEMENTAL FORM
TO THE MULTI-JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM
Casino Service Industry Enterprise Qualifiers
New Jersey Supplemental Form
to the Multi-Jurisdictional –
Casino Service Industry Enterprise Qualifiers
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 connection with an enterprise’s initial application for licensure 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.
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 an enterprise license applicant, a junket enterprise, or licensee,
pursuant to N.J.S.A. 5:12-92; or
2.
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.
N.J.A.C. 13:69A-7.7 requires qualifiers of enterprises to submit fingerprint cards with
their Personal History Disclosure Forms at the time of initial application for licensure
and application for retention of the license. Qualifiers may choose one of the two
following
methods
for
providing
the
required
fingerprint
cards:
NJDGE 09/11/2020
Page 1 of 12 Pages
Initials / Date: ____/_______
1.
Make an appointment with the Division’s Identification Unit located in the
Arcade Building, Tennessee Avenue and the Boardwalk in Atlantic City to be
fingerprinted. Call for an appointment at (609) 441-3050. Please be advised that
the Division now has the capability to record and reproduce fingerprints
electronically. This means that if you schedule an appointment at any time prior
to the due date of the application and you are fingerprinted by the Division, you
may not be required to be fingerprinted for any future applications. There is no
charge for fingerprinting.
Should you choose to be fingerprinted in Atlantic City, you may establish your
identity in accordance with N.J.A.C. 13:69A-7.2A at the time of your fingerprint
appointment by providing the original document(s) listed below in a) or b):
a)
A current and valid U.S. passport OR a Certificate of U.S. Citizenship OR
a Certificate of Naturalization OR a current identification card issued by
the U.S. Citizenship & Immigration Services (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 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 school 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 valid casino employee or casino key employee license, an
expired casino employee or casino key employee license issued
after 1998, or a valid casino service employee registration; or
(6)
A current and valid foreign passport with a proper USCIS
authorization.
Call (609) 441-3015 if you have any questions about identification documents.
Note: Upon arrival for your appointment, please advise Division personnel that you are
there to be fingerprinted for a casino service enterprise industry license application.
NJDGE 09/11/2020
Page 2 of 12 Pages
Initials / Date: ____/_______
2.
If you are unable to come to Atlantic City to be fingerprinted, fingerprint cards
are enclosed so that you can be fingerprinted at your local police department.
All qualifiers must provide the required set(s) of fingerprints on the enclosed
card(s). This must be done at the time of the initial application and with each
subsequent retention application. Further instructions are attached to the
enclosed fingerprint cards.
II.
BE SURE TO:
A.
Attach a recent (within the last six months) color photograph of yourself in the space
provided on page 5 of the Multi-Jurisdictional Personal History Disclosure Form.
B.
Sign the Release Authorization form on page 11 in the presence of a Notary Public and
have your signature notarized.
C.
Check to make sure that you have placed your initials and the date in the space
provided on the bottom of each page after you have checked your answers and are sure
they are complete.
III.
BEFORE YOU SUBMIT THIS FORM TO THE DIVISION, BE SURE THAT:
A.
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.
B.
You have placed documentation that you have been fingerprinted by the Division or that
you have submitted the appropriate fingerprint cards and information sheet.
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 retain a completed copy of this form for your own records.
IV.
FILING THIS FORM WITH THE DIVISION:
A.
Submit an original and one photocopy of this form, the Multi-Jurisdictional Personal
History Disclosure Form, and all attachments to:
New Jersey Division of Gaming Enforcement
Service Industry Licensing Bureau (SILB), Intake Unit
1300 Atlantic Avenue, 3
rd
Floor
Atlantic City, New Jersey 08401
B.
If the photocopy of this form or the photograph is not clear, the application will not be
accepted.
C.
Once the application is accepted, it becomes the property of the Division and may not
be withdrawn without the permission of the Division.
NJDGE 09/11/2020
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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 86(b) 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 79(a)(6) and 80c 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.
F.
Pursuant to 42 U.S.C. § 405(c)(2)(C)(i), N.J.S.A. 54:50-25, 42 U.S.C. § 666(a)(13), and
N.J.S.A. 2A:17-56.60, the Division of Gaming Enforcement is required to obtain your
Social Security number. Pursuant to these authorities, the Division of Gaming
Enforcement is also obligated to provide your Social Security number to:
1. The Director of Taxation to assist in the administration and enforcement of any tax
law, including for the purpose of reviewing compliance with State tax law and
updating and correcting tax records; and
2. The Probation Division or any other agency responsible for child-support
enforcement, upon request.
NJDGE 09/11/2020
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Initials / Date: ____/_______