(The application must be lodged in quadruplicate)
The Licensing Officer, [specify].
I (We), [name, occupation, and address of applicant], hereby apply for a licence to import the following goods into [specify] during the period [specify].
|New Zealand Tariff Item No||Full description of goods||*Country or countries from which it is desired to import||Quantity and CIF value (NZ currency)||Quantity and CIF value (NZ currency) of similar goods imported by the applicant, during [specify]||Quantity and value CIF (NZ currency) for which a licence to import is granted|
| || || || || |
|*If more than 1 country, show quantity and values in respect of each country in columns (4) and (5).|
Particulars as to manner of payment for the goods by applicant for licence, including name of bank in New Zealand or agent through which payment is to be arranged (if payment is to be made otherwise than directly to supplier of the goods, give name and address of person, firm, or company to whom payment is to be made): [specify]
I hereby declare that the particulars contained in this application are true and correctly stated in every respect.
Signature of applicant:
(The application should be signed by the applicant or by some responsible servant of the applicant on his behalf.)
A licence to import the above-mentioned goods to the extent shown in column (6) is hereby granted.