Renewal Application For A Compensated Casino Night Employee (Annually) Form - New Jersey Office Of The Attorney General
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4New Jersey Office of the Attorney General
Division of Consumer Affairs
Legalized Games of Chance Control Commission
124 Halsey Street, P.O. Box 46000
Newark, N.J. 07101
(973) 273-8000
Initial Application for a Compensated Casino Night Employee (Annually)
N.J.S.A. 5:8-1 et seq.
This application must be completed, signed by the applicant and notarized. It must be filed with the Legalized Games
of Chance Control Commission along with a nonrefundable, nontransferable application fee in the form of a certified
check or money order, payable to the Legalized Games of Chance Control Commission, in the amount of $100 for an
independent worker. A fee of $25 is required for a worker employed by one licensed casino night equipment
provider. Please submit two (2) copies of a recent (within the last six months) passport-style photograph along with
your application.
Note: Upon receiving notification from the Commission regarding its approval of an applicant's application, the
independent worker applicant will be required to forward a license fee in the form of a certified check or money order
payable to the Legalized Games of Chance Control Commission in the amount of $125.00. A licensing fee of $25 will
be required for a worker employed by a licensed casino night equipment provider will be required to forward a license
fee in the form of a certified check or money order payable to Legalized Games of Chance Control Commission in the
amount of $25.00.
Please print clearly.
A. Applicant Information
(For all applicants, if additional space is needed attach a notarized addendum to this application.)
Name of applicant: __________________________________________________________________________
First name Middle name Last name
Maiden name (if married female): _____________________________ Citizen of ________________________
Mailing address: ____________________________________________________________________________
Street address City
State ZIP code County
Home address (if different): ___________________________________________________________________
Street address City
State ZIP code County
Home telephone number:______________________ Business telephone number: _______________________ _
(Include area code)
(Include area code)
E-mail address: _______________________ Date of birth: ____________ Place of birth: __________________
Social Security number:________________________________ Race: ________________________________ _
Sex: ________ Height: _________ Weight: __________ Hair color: ___________ Eye color: _____________
1. Have you ever been convicted of a crime or violation of the law? Yes No
If "Yes," provide the details regarding each conviction, including the date of the offense, the date of the conviction, the
nature of the offense, the court in which the conviction was entered and the sentence imposed.
2. Do you have any criminal charges pending against you? Yes No
If "Yes," provide the details regarding the date, the place, the facts leading to the arrest or indictment, and the court in
which the matter is pending.
3. Have you ever been disciplined or sanctioned by any authority in any jurisdiction relating to any gaming
activity? Yes No
If "Yes," provide the details regarding the date, the place and the facts leading to the discipline
or sanctions, as well as the nature of the discipline or sanction imposed.
(Revised 4/6/16)
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