Multi-jurisdictional Personal History Disclosure Form

(1) A PHD-MA shall be submitted by each category 1 and category 2 qualifier and shall be in a format prescribed by the commission and may require the qualifier to provide the following information and such additional information as the commission may, in its discretion, determine: (a) Name, including maiden name and any aliases or nicknames and applicable dates of use; (b) Date of birth; (c) Physical description; (d) Current address and residence history; (e) Social Security Number, which information is voluntarily provided in accordance with 5 U.S.C. § 552a; (f) Citizenship and, if applicable, information regarding resident alien status, including information regarding passports; (g) Marital history, spouse, dependents and other family data; (h) The gaming licensee or qualifier, gaming vendor licensee or qualifier or holding company, as applicable, with which the qualifier is affiliated, and the nature of the qualifier's position with or interest in such entity; (i) Telephone number at the current place of employment; (j) Employment history of the qualifier and qualifier's immediate family; (k) Education and training; (l) Record of military service; (m) Government positions and offices presently or previously held, and the offices, trusteeships, directorships or fiduciary positions presently or previously held with any business entity; (n) Trusteeships or other fiduciary positions held by the qualifier and the qualifier's spouse, and any denial or suspension of, or removal from, such positions; (o) Current memberships in any social, labor or fraternal union, club or organization; (p) Licenses and other approvals held by or applied for by the qualifier or, where specified, the qualifier's spouse, in the Commonwealth of Massachusetts or any other jurisdiction, as follows: 1. Any professional or occupational license held by or applied for the by the qualifier or the qualifier's spouse; 2. Motor vehicle registrations and operator licenses held by or applied for the by the qualifier or the qualifier's spouse, and any revocation or suspension thereof; 3. Possession or ownership of any pistol or firearm, or any application for any firearm permit, firearm dealer's license, or permit to carry a pistol or firearm; 4. Any license, permit, approval or registration required to participate in any lawful gambling operation in the Commonwealth of Massachusetts or any jurisdiction held by or applied for by the qualifier; and 5. Any denial, suspension or revocation by a government agency of a license, permit or certification held by or applied for by the qualifier or the qualifier's spouse, or any entity in which the qualifier or the qualifier's spouse was a director, officer, partner or any owner of a 5% or greater interest; (q) Any interest in or employment presently or previously held by the qualifier with any entity which has applied for a permit, license, certificate or qualification in connection with any lawful gambling or alcoholic beverage operation in the Commonwealth of Massachusetts or any other jurisdiction; and any current employment or other association by the qualifier's family with the gambling or alcoholic beverage industries in the Commonwealth of Massachusetts or any other jurisdiction; (r) Civil, criminal and investigatory proceedings in any jurisdiction, as follows: Arrests, charges or offenses committed by the qualifier or any member of the qualifier's immediate family; Any instance where the qualifier has been named as an unindicted party or co-conspirator in a criminal proceeding or held as a material witness; 3. Any appearance before, investigation by or request to take a polygraph examination by any governmental agency, court, committee, grand jury or investigatory body, and any refusal to comply with a request to do so; 4. Any pardons, dismissals, suspensions or deferrals of any criminal investigation, prosecution, or conviction; 5. Lawsuits to which the qualifier was or is a party; Any citation or charge for a violation of a statute, regulation or code of any jurisdiction, other than a criminal disorderly persons, petty disorderly persons or motor vehicle violation; and 7. Any use, distribution, or possession of any narcotic, hallucinogenic, drug, barbiturate, amphetamine or other substance listed in M.G.L. c. 94C other than pursuant to a valid prescription issued by a licensed physician; (s) Any exclusion or barring from any casino, gaming establishment or gambling/gaming related entity in any jurisdiction; and (t) Financial data, as follows: 1. All assets and liability of the qualifier, and the qualifier's spouse and dependent children as indicated on the net worth statement and supporting schedules in a format prescribed by the commission, including cash, bank accounts, notes payable and receivable, real estate and income taxes payable, loans, accounts payable and any other indebtedness, contingent liabilities, securities, real estate interests, real estate mortgages and liens, life insurance, pension funds, vehicles and other assets; 2. Bank accounts, including any right of ownership in, control over or interest in any foreign bank account, and safe deposit boxes; Real estate interests held by the qualifier or the qualifier's spouse or dependent children; 4. Businesses owned; 5. Copies of Federal tax returns and related information; Judgments or petitions for bankruptcy, insolvency or liquidation concerning the qualifier or any business entity in which the qualifier held a 5% or greater interest, other than a publicly traded corporation, or in which the qualifier served as an officer or director; 7. Any business entity in which the qualifier was an owner, director or officer which has been placed under some form of governmental administration or monitoring; 8. Any garnishment or attachment of wages, charging order or voluntary wage execution, including the amount, court, nature of the obligation and the holder of the obligation; 9. Any repossessions of real or personal property; 10. Any guarantees, co-signatures or insuring of payments of financial obligations of any persons or business entities; 11. Status as executor, administrator or fiduciary of any estate; 12. Life insurance policies on the qualifier's life which name someone other than the qualifier's family as a beneficiary; 13. Positions held, assets held, or interest received in any estate or trust; 14. Whether the qualifier has ever been bonded for any purpose or been denied any type of bond, including the nature of the bond and if applicable, the reason for denial; 15. Insurance claims in excess of $100,000.00 by the qualifier or the qualifier's spouse or dependent children; 16. Referral or finder's fees in excess of $10,000.00; 17. Loans in excess of $10,000.00 made or received by the qualifier, the qualifier's spouse or dependent children; 18. Gifts in excess of $10,000.00 given or received by the qualifier or the qualifier's immediate family; 19. Brokerage or margin accounts with any securities or commodities dealer; 20. Currency exchanges in an amount greater than $10,000.00; 21. Information regarding any instance where the qualifier or any entity in which the qualifier was a director, officer or holder of a five percent or greater interest has traded in foreign currencies or in a foreign commodities exchange, sold or purchased discounted promissory notes or other commercial paper, or been a party to any leasing arrangements in excess of $50,000.00; and 22. Information regarding any ownership interest or financial investment by the qualifier in any entity which holds or is an applicant for a license issued by the commission, or in any gambling venture which does not require licensure by the commission, including persons providing or reasonably anticipated to provide the qualifier with support in the financing of such investment or interest; the extent and nature of the qualifier's involvement in the management and operation of the entity; whether the qualifier has or has agreed to assign, pledge or hypothecate such interest or investment, the nature and terms of any such transaction and a copy of any such agreement. (2) In addition to the information in 205 CMR 111.03(1), a completed PHD-MA shall include the following: (a) The name, address, occupation and phone number of persons who can attest to the qualifier's good character and reputation; (b) A waiver of liability as to the Commonwealth of Massachusetts and its instrumentalities and agents for any damages resulting from any disclosure and publication of information acquired during the license or investigation process; (c) Consent to inspection, searches and seizures and the supplying of handwriting exemplars; and (d) A signed, dated and notarized affidavit.