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INZ1209_National Security Check Form

OFFICE USE ONLY Client no.:Date received: / /

Application no.:

INZ1209_National Security Check Form

INZ1209_National Security Check Form

INZ1209_National Security Check Form

INZ1209_National Security Check Form

INZ1209_National Security Check Form

INZ1209_National Security Check Form

For further information on immigration visit

http://www.wendangku.net/doc/62c3df2304a1b0717ed5dd08.html

July 2013

A1 Name as shown in passport Family/last name

Given/first name(s)

A2 Date of birth

A3 Passport number (if applicable)

A4 Town/City of birth A5 Citizenships held

A6 Last residential address in home country

INZ1209_National Security Check Form

2 – National Security Check Form - July 2013

When filling in this form, please write clearly using CAPITAL LETTERS.

INZ1209_National Security Check Form

B 1 H a v e y o u e v e r b e e n r e f u s e d a v i s a /p e r m i t t o v i s i t , w o r k , s t u d y o r r e s i d e i n a n y c o u n t r y i n c l u d i n g N e w Z e a l a n d ?

N o G o t o C 1

.

Y e s P r o v i d e d e t a i l s

INZ1209_National Security Check Form

.

National Security Check Form - July 2013 –

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3

INZ1209_National Security Check Form

P l e a s e e n s u r e t h a t y o u p r o v i d e i n f o r m a t i o n a b o u t a l l p e r i o d s o f e m p l o y m e n t , u n e m p l o y m e n t a n d e d u c a t i o n . T h i s i n c l u d e s a n y p e r i o d w h e r e y o u u n d e r t o o k h o u s e h o l d /d o m e s t i c d u t i e s , v o l u n t a r y o r u n p a i d w o r k . F o r a n y p e r i o d w h e r e y o u w e r e n o t w o r k i n g o r s t u d y i n g , p l e a s e g i v e t h e d a t e s a n d e x p l a i n h o w y o u s u p p o r t e d y o u r s e l f . I f y o u d o n o t p r o v i d e t h e f u l l a n d c o m p l e t e h i s t o r i e s , y o u r a p p l i c a t i o n w i l l b e d e l a y e d w h i l e w e s e e k c l a r i f i c a t i o n f r o m y o u .

C 1 E d u c a t i o n h i s t o r y – I n c l u d e a c o m p l e t e h i s t o r y o f y o u r e d u c a t i o n f r o m s e c o n d a r y s c h o o l (h i g h s c h o o l ) o n w a r d s .

I d i d n o t a t t e n d s e c o n d a r y s c h o o l (h i g h s c h o o l ) o r h i g h e r e d u c a t i o n . G o t o C 2

INZ1209_National Security Check Form

.

4 – National Security Check Form - July 2013

When filling in this form, please write clearly using CAPITAL LETTERS.

C 2 E m p l o y m e n t h i s t o r

INZ1209_National Security Check Form

y

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INZ1209_National Security Check Form

D1 Do you have a national identity number, or other unique identifier that was issued to you by any government?

Yes National identity number/unique identifier No

D2 Have you completed military service in any country?

Yes Provide information about your military service including the dates of your military service, your position and rank, the unit or units that

you served in, and your role within each unit.

INZ1209_National Security Check Form

No

List any military identity numbers you were given

D3 Are you presently subject to military service obligations in any country?

Yes Go to D4 No If you are a citizen of a country in which compulsory military service exists, provide details.

INZ1209_National Security Check Form

D4 Have you been associated with any intelligence agency or group, or law enforcement agency?

Yes Describe how you were involved

INZ1209_National Security Check Form

No

D5 Have you been associated with any group or organisation that has used or promoted violence to further their aims?

Yes Describe how you were involved

INZ1209_National Security Check Form

No

D6 Have you ever committed or been involved in war crimes, crimes against humanity, and/or human rights abuses?

Yes Describe how you were involved

INZ1209_National Security Check Form

No

When filling in this form, please write clearly using CAPITAL LETTERS.

INZ1209_National Security Check Form

I declare that the information I have provided in this form is true and correct.

I authorise Immigration New Zealand to make any necessary enquiries about information on this form and/or

accompanying documentation and to share this information with other government agencies (including overseas agencies) to the extent necessary to make decisions about my immigration status.

I authorise any agency, whether in New Zealand or overseas, including but not limited to:

? border or immigration agencies

? education providers

? financial institutions

? foreign embassies and government authorities

? health care providers, and

? police or other law enforcement agencies,

that holds information (including personal information) related to information on this application form and/or

accompanying documentation, to disclose that information to Immigration New Zealand so that they can:

? make a decision on this application

? answer enquiries about my immigration status once my application has been decided.

I authorise any agency that holds information (including personal information) related to those matters to disclose that

information to Immigration New Zealand.

INZ1209_National Security Check Form

Signature of applicant Date

INZ1209_National Security Check Form

This section must be completed and signed by the applicant’s immigration adviser, or by any person who has assisted the applicant by providing immigration advice, explaining, translating, or recording information on the form for the applicant. If the applicant does not have an immigration adviser, and no one helped the applicant to fill in this form, this section does not have to be completed.

If you are unlicensed when you should be licensed under the Immigration Advisers Licensing Act 2007, Immigration New Zealand will return your client’s application. It is an offence to provide immigration advice without holding a licence. For more information, go to the Immigration Advisers Authority website http://www.wendangku.net/doc/62c3df2304a1b0717ed5dd08.html, or email info@http://www.wendangku.net/doc/62c3df2304a1b0717ed5dd08.html or write to them at PO Box 6222, Wellesley Street, Auckland 1141, New Zealand.

Name and address of person assisting applicant.

Given/first name(s)

Family/last name

INZ1209_National Security Check Form

Company name (if applicable) and address

INZ1209_National Security Check Form

Fax Email

I understand that after the applicant has signed this form it is an offence to change or add further information, change

any documents attached to the form, or attach any further documents to the form.

I note that the maximum penalty for this offence is a fine of up to NZ$100,000 and/or a term of imprisonment of up to

seven years. However, if changes are needed, the person making the changes must state on the form what information or documents have been changed and give reasons for the changes.

I certify that the applicant asked me to help them complete this form and any additional forms. I certify that the applicant

agreed that the information provided was correct before signing the declaration.

I have assisted the applicant as an interpreter/translator.

I have assisted the applicant with recording information on the form.

I have assisted the applicant in another way. Specify

I have provided immigration advice (as defined in the Immigration Advisers Licensing Act 2007) and my licence number

is 20.

I have provided immigration advice but am exempt from being licenced.

See http://www.wendangku.net/doc/62c3df2304a1b0717ed5dd08.html/adviserlicensing for more information about who is exempt from licensing.

Signature of person assisting Date D M Y Y

M Y

D Y

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