Nov. 9.] THE NEW ZEALAND GAZETTE. 2949

Form No. 2.

APPLICATION FOR A PERMIT TO ENTER THE COOK ISLANDS.

(To be filled up in the English language.)

To the Resident Commissioner, Cook Islands [or Niue].

I, [Full name], of [Present address], do hereby make this application to enter the Cook Islands accompanied by my wife, family, servants, and employees, and in support of the same submit the following particulars concerning myself and my wife, family, servants, and employees.

[Strike out all words not required, or modify the words to suit the case.]

(a.) Full name :

(b.) Nationality :

(c.) Place of birth and nationality of parents—
(1) Father :
(2) Mother :

(d.) Last place of permanent residence :

(e.) I was born at , on the day of , 1 .

(f.) Marital state :

(g.) If married, full name and age of wife, and full names and ages and sexes of children ; also full names, ages, and sexes of servants or employees [To be inserted only if accompanying the applicant] :

(h.) Occupation or business proposed to be undertaken in the Cook Islands, or purpose in coming to the Cook Islands :

(i.) The amount of money in English currency which I undertake to bring to Cook Islands :

(j.) Condition of mental and physical health (including particulars as to height, weight, and chest-measurement), and the condition of mental and physical health of the other persons to accompany him/her [Supported by a certificate from a qualified medical practitioner] :

(k.) Name of (a) a European language in which I am able to read and write fluently, or (b) any other language in which I am able to read and write fluently :

(l.) Intended place of future permanent residence in the Cook Islands (if known) :

(m.) That I am a person of good character and reputation, and that I have never been in prison or the recipient of charitable aid or in a mental hospital, and that I am not a disaffected or dangerous person or one who advocates the overthrow by force or violence of constitutional Government [To be supported by a certificate from a police officer or other public official] :

(n.) Address and full name of any relatives in the Cook Islands :

(o.) That I am prepared to swear or affirm that I will faithfully observe and obey the laws in force in the Cook Islands.

[Signature of applicant.]

Dated at this day of , 19 .

NOTE.—(1.) The applicant must forward along with his application two unretouched and unmounted half-length recent photographs of himself or herself, not to exceed in size 4½ in. by 3½ in., and to be not less than 3 in. by 2 in.

(2.) This application must be filled up in the English language.

(3.) If the applicant intends to remain only temporarily in the Cook Islands, it will not be necessary to fill in particulars under (c), (k), (l), and (n), but he must state the length of time during which he desires to stay. Unless for extraordinary reasons, temporary permits will be granted only for six months.

(4.) This application must be sent by post from the country where the applicant was born, or where he has resided for one year prior to the date of application.

F. D. THOMSON,
Clerk of the Executive Council.