1084
THE NEW ZEALAND GAZETTE.
[No. 38

SCHEDULE.

[Form No. 1.

Employment Promotion Act, 1936.
APPLICATION FOR REGISTRATION.

The Postmaster,

In accordance with the provisions of section 6 of the Employment Promotion Act, 1936,
I hereby apply for registration, and I declare the following particulars to be true and
correct :—

Surname :
Christian name (in full) :
Residential address :
Occupation or calling :
Name and address of employer (if any) :
Business address (if any) :
Date of my attaining twenty years of age : [Required only when applicant attained age of
twenty after the commencement of the Act.]
Date of my return to New Zealand : [Required only when applicant, a resident of New
Zealand, was absent from New Zealand at time of the commencement of the Act.]
Date when I became a resident of New Zealand : [Required only when applicant became
a resident of New Zealand after the commencement of the Act.]

Signature of applicant :

Date :

Signed in the presence of (witness) :
Certificate of Registration issued, No.

. . . . . . . . . . . . , Postmaster.
[DATE-STAMP
OF ISSUING OFFICE.]

[Form No. 2.

Employment Promotion Act, 1936.
CERTIFICATE OF REGISTRATION.

Surname : . Christian name :
Residential address at date of registration :
Occupation :
Date of issue of certificate :

I hereby certify that the above-named person has been duly registered under
section 6 of the Employment Promotion Act, 1936.

. . . . . . . . . . . . , Postmaster.
[OFFICE
DATE-STAMP.]

[Form No. E.T. 55.

Employment Promotion Act, 1936.
DECLARATION OF INCOME OTHER THAN SALARY OR WAGES.

Coupon-book No. [It is essential that this be shown].

The Commissioner, Employment-tax Division,
Land and Income Tax Department,
Wellington, C. 1.

Surname [in block letters] :
Christian name or forename (in full) :
Occupation :
Address :

I do solemnly and sincerely declare that the following is a true and complete statement of income (*) derived by me from all sources other than salary or wages during the
year ended 31st March, 193 .

Statement of Income derived as aforesaid.

£ s. d.

(a) From any profession or business (including (†) farming) . . . .
(b) From interest (including tax-free war loans and debentures) . .
(c) From dividends from companies (1) trading in New Zealand. . . .
From dividends from companies (2) trading outside New Zealand . .
(d) From rents and royalties . . . . . . . .
(e) From goodwill derived from any lease, license, or easement affecting
land . . . . . . . . . .
(f) From dividends paid or profits credited by any building society . .
(g) From pension, annuity, superannuation, or retiring-allowance . .
(h) From estate of . . . . . . . . . .
(i) From any other source (state source) . . . . . . . .

Usual signature :

Date :

(*) NOTE.—For the purpose of this form and of the employment charge, the term
“ income ” does not include compensation received under the Workers’ Compensation
Act, 1922, pensions received under the War Pensions Act, 1915, or any other pension
granted in Great Britain or within the British Dominions in respect of the Great War.
(†) Declarations from farmers should be accompanied by Form E.T. 58, except
when a return of income is made under the Land and Income Tax Act, 1923.

This form, together with the amount of employment charge payable, must be
presented at any money-order office, or forwarded, postage paid, to the Commissioner,
Employment-tax Division, Land and Income Tax Department, Wellington, C. 1.

C. A. JEFFERY,
Clerk of the Executive Council.