✨ Customs Application Form
NEW ZEALAND GAZETTE, No. 64
17 JUNE 2014
Nominated Representative Page
This page is to be completed if you are required to nominate a person as your representative. Please submit supplementary pages if more than one representative is required.
Representative Details
Passport or Drivers Licence:
Mandatory – a copy must be submitted with the application
Surname:
First name:
Previous names:
Alias:
Date of birth:
Country of birth:
Gender:
Occupation:
Contact Details – Home
Full Street Address:
Suburb:
City:
Post code:
Landline:
Mobile:
Contact Details – Work
Full Street Address:
Suburb:
City:
Post code:
Company Name:
Client code:
Full Postal Address:
Suburb:
City:
Post code:
Business/DDI:
Email:
Web:
Criminal convictions
Note: Information on criminal convictions does not have to be provided if you meet the eligibility criteria of the Criminal Records (Clean Slate) Act 2004. Information on these criteria is available on the Ministry of Justice website.
Do you have convictions for any of the offences as specified in section 132B of the Customs & Excise Act 1996? ☐ Yes ☐ No
If you answer "Yes", please list what these are:
Please provide any further information you think is relevant to your conviction(s):
Declaration
I, (full name),
of (address),
declare that the information I have provided is true, correct and complete in every particular.
Signature of nominated representative:
Date:
Note: Making a declaration that is erroneous in a material particular is an offence under the Customs and Excise Act 1996. Making a false declaration may be an offence under the Biosecurity Act 1993, the Food Act 1981, and the Agricultural Compounds and Veterinary Medicines Act 1997.
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NZ Gazette 2014, No 64
✨ LLM interpretation of page content
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Customs (Application for JBMS User Registration) Rules 2014
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🏭 Trade, Customs & IndustryCustoms, JBMS user registration, rules, forms, Trade Single Window, personal identification, English translation, body corporate, Certificate of Incorporation, passport, driver's licence