✨ Nominated Representative Form
NEW ZEALAND GAZETTE, No. 18 — 26 FEBRUARY 2015
FORM CIC 1 FEBRUARY 2015
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
Surname:
First name:
Date of birth:
Gender:
Contact Details – Home
Full Street Address:
Full Postal Address:
Suburb:
City:
Post code:
Landline:
Mobile:
Email:
Previous names:
Alias:
Country of birth:
Occupation:
Suburb:
City:
Post code:
Contact Details – Work
Company Name:
Full Street Address:
Full Postal Address:
Suburb:
City:
Post code:
Business/DDI:
Email:
Client code:
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 2015, No 18
✨ LLM interpretation of page content
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Supplementary form to an Application to be a Joint Border Management System user for the purpose of Trade Single Window online registrations
(continued from previous page)
🏭 Trade, Customs & IndustryTrade Single Window, user registration, Joint Border Management System, application form, client codes, notification preferences, criminal convictions, declaration