1736 NEW ZEALAND GAZETTE, No. 64 17 JUNE 2014

Schedule 2

FORM 9A MAY 2014

Joint Border Management System – Registered User Application - Organisation

Section 132 of the Customs and Excise Act 1996

For enquiries phone 0800 428 786

To apply for registration as a user of an integrated border management computerised system (JBMS), please supply the information as required.

Organisation Details

Company Name: ...................................................................................................................................................................................

Company Registration Number: ....................................................... GST/IRD Number: .........................................................................

Full Street Address: ......................................................................... Full Postal Address: .........................................................................

Suburb: ............................................................................................. Suburb: .............................................................................................

City: ....................................................... Post code: ....................... City: ....................................................... Post code: .......................

Business: ....................................................... Fax: ....................................................... Mobile: .......................................................

Email: ............................................................................................... Web: ...............................................................................................

Nominated Representative

IMPORTANT: If you are an overseas organisation or New Zealand-based organisation then you must nominate one or more individuals ordinarily resident in New Zealand as your representative. Representatives will have access to your or your organisation’s information and will have access to amend this information. Please submit supplementary pages if more than one representative is required.

Surname: ........................................................................................... Previous names: ...........................................................................

First name: ....................................................................................... Alias: ................................................................................................

Date of birth: ................................................................................... Country of birth: .............................................................................

Gender: ............................................................................................ Occupation: .....................................................................................

Full Street Address: ......................................................................... Full Postal Address: .........................................................................

Suburb: ............................................................................................. Suburb: .............................................................................................

City: ....................................................... Post code: ....................... City: ....................................................... Post code: .......................

Landline: ....................................................... Mobile: ....................................................... Email: .......................................................

Business/DDI: ....................................................... Email: ....................................................... Web: .......................................................

Criminal Convictions (To be completed by nominated representative)

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):
....................................................................................................................................................................................................................................

Signature of 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

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