Initial Application Form For Bingo/raffle Equipment Providers, Instant Raffle Equipment Distributors/manufacturers, And Casino Night/armchair Race Equipment Providers - New Jersey Office Of The Attorney General Page 3

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D. Identification Statement for Individuals: Must be completed by each person required to be named in this
application. Part D may be reproduced.
Name of individual: _______________________________________________________________________
First name Middle name Last name
Maiden name (if married female): ____________________________________________________________
Mailing address (if different): _______________________________________________________________
Street address City
State ZIP code County
Home address (if different): _________________________________________________________________
Street address City
State ZIP code County
Business telephone number:__________________________ Home telephone number: __________________
(Include area code)
(Include area code)
Social Security number:__________________________ E-mail address: ____________________________
Sex: ____ Height:_____ Weight: ______ Hair color:______ Eye color: ________ Race:_________________
Present occupation or employment:____________________________________ Since: _________________
If your present employment has been for fewer than 10 years, provide information about your previous
occupations or employment:
1.______________________________________________________ From: ________ to _______________
2.______________________________________________________ From: ________ to _______________
List any and all other names by which you are known or have been known: _ __________________________
_______________________________________________________________________________________
Have you ever been enjoined or barred from any business in any jurisdiction? Yes No
If "Yes," attach a statement to this application providing complete and accurate details.
Have you ever been engaged, employed by or connected with anyone who rented, leased, sold or provided any space,
equipment, paraphernalia or supplies, or rendered services used in or in connection with the holding, operating or
conducting of bingo, raffles, instant raffles, casino nights or armchair races? Yes No
If "Yes," attach a statement to this application providing the following information:
Name of person/business: __________________________________________________________________
Type of license, certificate or registration: ______________________________________________________
Issuing agency: ______________________________________ Date issued: _________________________
Is the license, certificate or registration currently valid? Yes No
If "No," attach a statement to this application providing the complete and accurate details.
Have you ever been convicted of any violation of a law or ordinance, except minor traffic offenses? Yes No
If "Yes," attach a statement to this application disclosing the complete and accurate details.
Are there any criminal charges pending against you? Yes No
If "Yes," attach a statement to this application disclosing the complete and accurate details.

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