NEW ZEALAND GAZETTE, No. 25 — 9 MARCH 2017

FORM C11

Application for Customs controlled area licence

Section 11, Customs and Excise Act 1996

To the New Zealand Customs Service at (nearest Customs port):..........................................................................................................

1 Name of applicant:....................................................................................................................................................................
(Full registered company name or partnership/sole trader/trust names to be shown)

Trading as (where applicable) .. .................................................................................................................................................

2 New Zealand Company Registration Number OR New Zealand Business Number (NZBN) (if applicable): .....................

3 Applicant TSW Registration Number (if available) .. ...........................................................................................................

4 If the applicant is a sole trader or individual:

Date of Birth .. ...........................................................................................................................................................................

Country of Birth .. .....................................................................................................................................................................

Gender .. ...................................................................................................................................................................................

5 Applicant Contact Details

Contact numbers: .....................................................................................................................................................................

Email address: ..........................................................................................................................................................................

6 External Reference Number .. ..............................................................................................................................................

7 Physical Address of the applicant:

Street Number:..........................................................................................................................................................................

Unit Number:.................................................................. Floor Level: ....................................................................................

Property Name: ............................................................... Property Type:................................................................................

Street Name:.................................................................... Street Type: ...................................................................................

Suburb :............................................................................ Town/City: .....................................................................................

State:................................................................................ Country:..........................................................................................

Postcode:.........................................................................

8 Postal Address of the applicant (if not same as above)

Street Number:..........................................................................................................................................................................

Unit Number:.................................................................. Floor Level: ....................................................................................

Property Name: ............................................................... Property Type:................................................................................

PO Box:............................................................................ Private Bag: ...................................................................................

Street Name:.................................................................... Street Type: ...................................................................................

Suburb :............................................................................ Town/City: .....................................................................................

State:................................................................................ Country:..........................................................................................

Postcode:.........................................................................

9 Names, Position Held, Phone Number and Email Address of key contact personnel for the applicant:

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