✨ Customs Application Form
NEW ZEALAND GAZETTE, No. 25 — 9 MARCH 2017
Nominated Representative Page
This page to be completed if you are required to nominate a person as your representative.
Please submit supplementary pages if more than one repre(sent)ative is required.
Representative Details
Passport or Drivers Licence
Mandatory - a copy must be submitted with this application
Surname: ___
Previous names: __
First name: __
Alias: __
Date of birth: ___
Country of birth: ____
Gender: ____
Occupation:
Contact Details – Home
Full Street Address: ___
Suburb: ____ City: ___
Post code: __
Full Postal Address: __
Suburb: ____ City: ___
Post code: __
Landline: _
Mobile: ___
Email: __
Contact Details – Work
Company Name: ____
Client code: __
Full Street Address: __
Suburb: ____ City: ___
Post code: __
Full Postal Address: __
Suburb: ____ City: ___
Post code: __
Business/DOI: ____
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.
Next Page →
NZ Gazette 2017, No 25
✨ LLM interpretation of page content
🏭
Joint Border Management System - Registered User Application - Nominated Representative Details
(continued from previous page)
🏭 Trade, Customs & IndustryCustoms, Border Management, User Registration, Application Form, Trade Single Window, Notification Preferences, Criminal Convictions, Declaration, Nominated Representative