Fillable Printable Vendor Registration Supplemental Disclosure Form - New Jersey

Vendor Registration Supplemental Disclosure Form - New Jersey

STATEOFNEWJERSEY

DivisionofGami ngEnforcement

VENDORREGISTRATION

SUPPLEMENTALDISCLOSUREFORM

NJDGE2011 Page 1 of4Pages

VendorRe gistration Supplemental Disclosure Form

INSTRUCTIONS

I. COMPLETINGTHISFORM:

A. This form is to be completed and filed DIRECTLY with the Division of Gaming

Enforcement(Division)byavendorafteracasinolicensee/applicanthasfiledaVendor

RegistrationDisclosureFormoni tsbehalf.

B. Wi thin30daysofthefilingofaVendorRegistrationForm,thevendormustcomplete

andfilethi sformwiththeDivisionatthefollowingaddress:

NewJerseyDivisionofGamingEnforcement

ServiceIndustryLicensingBureau(SILB),IntakeUnit

1300AtlanticAvenue,3

rd

Floor

AtlanticCity,NJ08401

Attn.:VendorRegistrationSupplementalDisclosureForm

C. Pleasetypeallinformationandanswerallquestionscompl etely.

D. Respond “None”or“DoesNotApply,”ifappropriate.

E. For the purpose of question 8, the word “arrest” includes any detaining, holding, or

taking into custody by any police or other law enforcement authorities, in order to

answerfortheallegedperformanceofanyoffenseinNe wJersey,oranywhereelse;the

word “Charge” includes any indictment, complai nt, information, summons, or other

noticeoftheallegedcommissionofanyoffenseinNewJerseyoranywhereelse;and

theword“Offense”incl udesallhighmisdemeanors,felonies,misdemeanors,disorderly

personsoffenses,andjuvenileviolations.Pleaseno tethatanyarrestorcharge,which

hasbeenthesubjectofalawfulcourtorderorexpungementorsealing,neednotbe

disclosed,if suchorderentitlestheindividualtoanswer“No” tosuchinquiry.

F. Ifyouanswer“Yes”toquestion8,theDivisionmayrequireyoutoprovideanyevidence

of rehabilitation, such as good conduct in prison or in the community, counseling or

psychiatric treatment received, acquisition of additional academic or vocational

schooling, successful parti ci pation in correctional work‐release programs, or the

recommendation of persons who have or have had the individual under their

supervision.

Note: All enterprises, entities and individuals identified on this form, once completed, have the

affirmativeresponsibilityandcontinuingdutytocooperateinanyinquiryorinv estigationconducted

bytheDivisionandtoprovideanyassistanceorinformation requestedorrequiredbytheDivision.

Th e Division may deny registration to any enterprise that supp lies information which is untrue or

mislead ing.

NJDGE2011 Ini tialsofthePersonSupplyingtheInformationonthisFormand/orthePersonFilingthisForm:__________________

Page 2 of4Pages

VENDORREGISTRATIO NSUPPLEMENTALDISCLOSURE FORM

1. NAMEOFTHEENTERPRISE:

2. TRADINGAS(T/A)ORDOINGBUSINESSAS(D/B/A)ORFORSERVICESOF(F/S/O):

3. VENDOR ID#(ifknown):

___________________________ ________ ____________

4. TELEPHONENUMBER:

___________________________ ________ ____________

5. ADDRESSFROMWHICHBUSINESS ISCONDUCTEDWITHCASINOLICENSEEORAPPLICANTS:

ADDRESS Number/Street City State ZipCode COUNTRY

MAILING ADDRESS, ifdifferent(P.O.B ox,C ity,State,ZipCode,Country)

WEBSITE(URL)

6. FEDERALEMPLOYERIDENTIFICATIONNUMBER:

___________________________ ________ ____________

7. LISTANYENTITY(IES)ORINDIVIDUAL(S)IDENTIFIEDINYOURANSWERSTOQUESTIONS9AND

10OFTHEVENDORREGISTRATIONFORM:

NJDGE2011 Ini tialsofthePersonSupplyingthe InformationonthisFormand/orthePersonFilingthisF orm:__________________

Page 3 of4Pages

8. Hastheenterprise,oranyentity or individualidentifiedi nQuestion7above,everbeenindicted,

chargedwithorconvictedofacriminalordisorderlypersonsoffense,apartytoornamedasan

unindictedco‐conspirator,orarrestedorcharged,evenifnotconvicted,withanyfelony,crime ,

misdemeanor,disorderlypersonsoffense, juvenileoffense,orotheroffense(otherthanatraffic

violation),inany proceedinginNewJerseyoranywhereel se? Ifso,expl ainandincludeanycase,

file,docket,orjudgmentnumber.

________________________________________________________________________

9. Hastheenterprise,oranyentityorindividualidentifiedinQuestion7above,ever:

a) heldanyli cense,permit,approval,orregistrationinthisoranyotherjurisdiction?Ifso,

explainandincludeanylicense,permit,approval,orregistrationnumberoridentifier:

________________________________________________________________________

b) been denied, suspended, revoked, or withdrawn any license, permit, approval, or

registration in this or any other juri sdiction? If so, explain and include any license,

permit,approvalorregi strationnumberofidentifier:

________________________________________________________________________

________________________________________________________________________

NJDGE2011 Ini tialsofthePersonSupplyingthe InformationonthisFormand/orthePersonFilingthisF orm:__________________

Page 4 of4Pages

c) hadajudgment,order,consentdecree,orconsentorder,pertainingtoaviolationoran

allegedviolationofthefederallawsofanystate,provinceorcountry,enteredagainst

it?Ifso,explainandincludeanycase,file,docket,orjudgmentnumber:

________________________________________________________________________

10. DoestheenterpriseoranyentityorindividualidentifiedinQuestion7above,oweanydebtto

theStateofNewJersey?Ifso,explain:

________________________________________________________________________

11. Name,posi ti on/title,ande‐mailaddressofpersonsupplyingtheinformationonand/orfiling

thisform:

NameandTitle

CellNumberwithAreaCo de E‐MailAddress FaxNumber(ifavailable)

Whocertifiesthathe/sheisauthorizedtoactonbehalfoftheabove‐namedenterprise

and that theforegoing statements made by him/her, on behalf of theenterprise, are

true,andifanyoftheforeg oingstatementsmadebyhim/herarewillfullyfalse,he/she

issubjecttopunishment.

____________________ ___________________________(LegalSignature)

(Date) (SignatureofApplicant)

THISFORMMUSTBEFILEDDIRECTLYWITHTHEDIVISIONOFGAMINGENFORCEMENT