First name(s):

Middle name(s):

Last name(s):

Gender:

Occupation:

Date of birth:

Full residential address:

Full address at which documents relating to the application may be served on you, if different from residential address:

Daytime contact number:

Home telephone number [optional]:

Mobile number [optional]:

Fax number [optional]:

Email address [optional, unless applying by electronic means]:

If you are known by, or have ever been known by, another name, provide details.

First name(s):

Middle name(s):

Last name(s):

If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.

Licence number:

Certificate of approval number:

Provide the full address of every place of business from which you propose to carry on the business or businesses to which the application relates.

Specify which of the addresses given under “Place(s) of business” is your proposed principal place of business.

Specify the particular class or classes of business that you propose to carry on.

Private investigator

Security technician

Security consultant

Confidential document destruction agent

Property guard

Personal guard

Crowd controller

Repossession agent

Note: Section 62 of the Private Security Personnel and Private Investigators Act 2010 lists certain grounds that may disqualify you from being granted a licence or certificate of approval. However, if you answer that you have met any of the grounds of disqualification listed below, you may provide evidence to the Licensing Authority with your application relating to your character, circumstances, or background. The Licensing Authority may still grant your application, but only if the Authority is satisfied that you are suitable to carry on the class or classes of business to which the application relates. Please note that no refund is payable if your application is unsuccessful.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.

I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).

I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.

I have/have not*, within the past 7 years, been convicted of an offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an offence under section 10, 11, 12A, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.

I have/have not*, within the past 7 years, been convicted of an offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an offence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.

I have/have not*, within the past 7 years, been convicted of an offence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

I have/have not*, within the past 7 years, been convicted of an offence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a person without a relevant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.

I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval). [You must provide proof of meeting those requirements with this application.]

I have not/have*, within the past 5 years, had 12 months’ relevant experience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

Note: This ground applies only to applications for licences for a class of private security business other than that of repossession agent. You must provide details of relevant experience with this application.

I am applying for a licence as a repossession agent and I have/have not*, within the past 5 years, had 12 months’ relevant experience—

Note: Section 24 of the Private Security Personnel and Private Investigators Act 2010 also requires that you specify these matters. You may provide further information in support of your application (for example, evidence of your character, circumstances, or background) if you have specified a conviction or order as follows:

I have/have never* been convicted outside New Zealand of an offence.

I have/have never* had an order imposed in relation to myself by any court or tribunal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

If you wish to work, while your application for a licence is being processed, for a licensee as a responsible employee of a class that corresponds to the class or classes of private security business that you propose to carry on if your application for a licence is successful, you may be eligible for a temporary certificate of approval. This will incur an additional fee.

I wish/do not wish* to apply for a temporary certificate of approval.

If you wish to apply for a temporary certificate of approval and are currently employed, you must supply the following employment details:

Name(s) of any current employer(s):

Note: Only the forms of photo identification listed below are adequate to verify your identity. You must provide details of one of the forms of identification. The form of identification must not have expired more than 2 years ago. You must bring that identification with you to be verified when you collect your licence and identification badge, if your application is successful.

New Zealand driver licence*

Number:

Version number:

Expiry date:

Passport*

Passport number:

Date issued:

Expiry date:

Nationality as shown on passport:

18+ card issued by the Hospitality Association of New Zealand*

Number:

Firearms licence issued under section 24 of the Arms Act 1983*

Number:

If your application is successful, you must collect your licence and identification badge from a branch or outlet of the organisation that produces the licence; or if there is no such organisation, from the address specified on the Licensing Authority Internet site. Please see the Licensing Authority’s Internet site for details. Complete the following if the Internet site indicates that there is an organisation producing the licence:

Preferred branch/outlet:

I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.

Company registered name:

Company trading name:

Company registration number:

Current number of company officers:

If the company has previously held a licence under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide the licence number.

Licence number:

Provide the full address of every place of business from which the company proposes to carry on the business or businesses to which the application relates.

Specify the address of the company’s proposed registered office.

Provide the contact details of the person the Licensing Authority can contact regarding this application.

Name:

Daytime contact number:

Home telephone number [optional]:

Mobile number [optional]:

Fax number [optional]:

Email address [optional, unless applying by electronic means]:

Specify the particular class or classes of business that the company proposes to carry on.

Private investigator

Security technician

Security consultant

Confidential document destruction agent

Property guard

Personal guard

Crowd controller

Repossession agent

Describe the nature of all other business carried on or proposed to be carried on by the company.

Nature of business:

Note: Section 63 of the Private Security Personnel and Private Investigators Act 2010 lists certain grounds that may disqualify a company from being granted a licence. However, if you answer that any of the grounds of disqualification listed below apply, or any of the grounds of disqualification relating to company officers apply (see below), you may provide evidence to the Licensing Authority with your application relating to the suitability of the company to hold a licence. The Licensing Authority may still grant the company a licence, but only if the Authority is satisfied that the company is suitable to carry on business in the class or classes of business to which the application relates. Please note that no refund is payable if your application is unsuccessful.

The company has/has not*, within the past 7 years, been convicted of an offence under section 10, 11, 12, 12A, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.

The company has/has not*, within the past 7 years, been convicted of an offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

The company has/has not*, within the past 7 years, been convicted of an offence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

The company has/has not*, within the past 7 years, been convicted of an offence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.

The company has/has not*, within the past 7 years, been convicted of an offence under the Private Security Personnel and Private Investigators Act 2010 of operating while unlicensed or employing or engaging a person without a certificate of approval, or an offence under section 16, 343, or 52 of the Private Investigators and Security Guards Act 1974.

The company does/does not* hold a licence that has been suspended.

The company has/has not*, within the past 7 years, had a licence cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

The company has/does not have* any officer of the company who was, or is, an officer of another company (whether or not that other company is still in existence) that, within the past 7 years, had a licence cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

Note: Section 25 of the Private Security Personnel and Private Investigators Act 2010 also requires that the company specifies these matters. You may provide evidence to the Licensing Authority with the application relating to the suitability of the company to hold a licence. The Licensing Authority may still grant the company a licence, but only if the Authority is satisfied that the company is suitable to carry on business in the class or classes of business to which the application relates. Please note that no refund is payable if your application is unsuccessful.

The company has/has never* been convicted outside New Zealand of an offence.

Note: An officer, in relation to a company, is defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

This section of the form must be completed by every officer of the company.

First name(s):

Middle name(s):

Last name(s):

Gender:

Occupation:

Date of birth:

This section of the form must be completed by every officer of the company.

Full residential address:

Full address for communications about this application, if different from residential address:

Daytime contact number:

Home telephone number [optional]:

Mobile number [optional]:

Fax number [optional]:

Email address [optional, unless applying by electronic means]:

This section of the form must be completed by every officer of the company.

If you are known by, or have ever been known by, another name, provide details.

First name(s):

Middle name(s):

Last name(s):

This section of the form must be completed by every officer of the company.

If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.

Licence number:

Certificate of approval number:

This section of the form must be completed by every officer of the company.

Note: Section 63 of the Private Security Personnel and Private Investigators Act 2010 applies the grounds of disqualification listed under section 62 of the Act to company officers as grounds for disqualifying a company from being granted a licence. However, if you answer that you have met any of the grounds of disqualification listed below, you may provide evidence to the Licensing Authority with your application relating to your character, circumstances, or background. The Licensing Authority may still grant the company a licence, but only if the Authority is satisfied that the company is suitable to carry on the class or classes of business to which the application relates. Please note that no refund is payable if the application is unsuccessful.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.

I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).

I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.

I have/have not*, within the past 7 years, been convicted of an offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an offence under section 10, 11, 12A, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.

I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an offence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.

I have/have not*, within the past 7 years, been convicted of an offence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

I have/have not*, within the past 7 years, been convicted of an offence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a person without a relevant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.

I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

Note: It is a ground of disqualification for a company if all of its officers meet the next 2 grounds of disqualification.

I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval). [You must provide proof of meeting those requirements with this application.]

I have not/have*, within the past 5 years, had 12 months’ relevant experience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

Note: This ground applies only to applications for licences for a class of private security business other than that of repossession agent. You must provide details of relevant experience with this application.

The company is applying for a licence as a repossession agent and I have/have not*, within the past 5 years, had 12 months’ relevant experience—

This section of the form must be completed by every officer of the company.

Note: Section 25 of the Private Security Personnel and Private Investigators Act 2010 also requires that you specify these matters. You may provide further information in support of your application (for example, evidence of your character, circumstances, or background) if you have specified a conviction or order as follows:

I have/have never* been convicted outside New Zealand of an offence.

I have/have never* had an order imposed in relation to myself by any court or tribunal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

This section of the form must be completed by every officer of the company.

I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.

Complete the following if you are applying for an individual licence:

Take notice that I, [full name], of [town or city], am applying to the Private Security Personnel Licensing Authority for an individual licence to operate [class(es) of business].

Complete the following if you are applying for a company licence:

Take notice that [registered name of company], [trading name of company if different from registered name], [company registration number], operating at [registered office of company] is applying to the Private Security Personnel Licensing Authority for the company to be licensed to operate [class(es) of business].

All notices of intention to apply for a licence must contain the following:

Any person who wishes to object to the granting of a licence to the applicant must give notice of the objection to the Private Security Personnel Licensing Authority not later than 1 month after the date of the publication of this notice.

No objection may be made except on one of the grounds set out in section 29 of the Private Security Personnel and Private Investigators Act 2010.

The notice of objection must state the grounds of the objection.

The Private Security Personnel Licensing Authority must serve a copy of any notice of objection on the applicant within 7 days after it has been filed with the Authority.

Full name:

Class(es) of business:

Principal place of business:

Other authorised place(s) of business:

Licence number:

Expiry date:

Version number:

Conditions [if any]:

[Insert photograph]

Registered name:

Class(es) of business:

Registered office:

Other authorised place(s) of business:

Trading name [if different from registered name]:

Licence number:

Expiry date:

Version number:

Conditions [if any]:

Company registered name:

Company trading name [if different from registered name]:

Company registration number:

Registered office of company:

Licence number:

Version number:

Class(es) of business:

Conditions [if any]:

First name(s):

Middle name(s):

Last name(s):

Gender:

Occupation:

Date of birth:

This section of the form must be completed by the proposed officer of the company.

Full residential address:

Full address for communications about this application, if different from residential address:

Daytime contact number:

Home telephone number [optional]:

Mobile number [optional]:

Fax number [optional]:

Email address [optional, unless applying by electronic means]:

This section of the form must be completed by the proposed officer of the company.

If you are known by, or have ever been known by, another name, provide details.

First name(s):

Middle name(s):

Last name(s):

This section of the form must be completed by the proposed officer of the company.

If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.

Licence number:

Certificate of approval number:

This section of the form must be completed by the proposed officer of the company.

Note: Section 40 of the Private Security Personnel and Private Investigators Act 2010 applies the grounds of disqualification listed under section 62 of the Act to proposed company officers.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.

I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).

I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.

I have/have not*, within the past 7 years, been convicted of an offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an offence under section 10, 11, 12A, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.

I have/have not*, within the past 7 years, been convicted of an offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an offence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.

I have/have not*, within the past 7 years, been convicted of an offence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

I have/have not*, within the past 7 years, been convicted of an offence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a person without a relevant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.

I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval). [You must provide proof of meeting those requirements with this application.]

I have not/have*, within the past 5 years, had 12 months’ relevant experience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

Note: This ground applies only if the company has a licence for a class of private security business other than that of repossession agent. You must provide details of relevant experience with this application.

The company has a licence as a repossession agent and I have/have not*, within the past 5 years, had 12 months’ relevant experience—

This section of the form must be completed by the proposed officer of the company.

I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.

First name(s):

Middle name(s):

Last name(s):

Gender:

Occupation:

Date of birth:

Full residential address:

Full address for communications about this application, if different from residential address:

Daytime contact number:

Home telephone number [optional]:

Mobile number [optional]:

Fax number [optional]:

Email address [optional, unless applying by electronic means]:

If you are known by, or have ever been known by, another name, provide details.

First name(s):

Middle name(s):

Last name(s):

If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.

Licence number:

Certificate of approval number:

Specify the particular class or classes of responsible employee in relation to which you are seeking a certificate of approval.

Private investigator employee

Security technician employee

Security consultant employee

Confidential document destruction agent employee

Property guard employee

Personal guard employee

Crowd controller employee

Repossession employee

Specify the names of all your current employers, if you are employed.

Name(s) of any current employer(s):

Note: Section 46 of the Private Security Personnel and Private Investigators Act 2010 applies the grounds of disqualification listed under section 62 of the Act to applicants for certificates of approval. However, if you answer that you have met any of the grounds of disqualification listed below, you may provide evidence to the Licensing Authority with your application relating to your character, circumstances, or background. The Licensing Authority may still grant your application, but only if the Authority is satisfied that you are suitable to work in the class or classes of responsible employee to which the application relates. Please note that no refund is payable if your application is unsuccessful.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.

I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).

I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.

I have/have not*, within the past 7 years, been convicted of an offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an offence under section 10, 11, 12A, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.

I have/have not*, within the past 7 years, been convicted of an offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an offence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.

I have/have not*, within the past 7 years, been convicted of an offence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

I have/have not*, within the past 7 years, been convicted of an offence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a person without a relevant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.

I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval). [You must provide proof of meeting those requirements with this application.]

Note: Section 46 of the Private Security Personnel and Private Investigators Act 2010 also requires that you specify these matters. You may provide further information in support of your application (for example, evidence of your character, circumstances, or background) if you have specified a conviction or order as follows:

I have/have never* been convicted outside New Zealand of an offence.

I have/have never* had an order imposed in relation to myself by any court or tribunal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

If you wish to work as a responsible employee while your application for a certificate of approval is being processed, you may be eligible for a temporary certificate of approval. This will incur an additional fee.

I wish/do not wish* to apply for a temporary certificate of approval.

Note: Only the forms of photo identification listed below are adequate to verify your identity. You must provide details of one of the forms of identification. The form of identification must not have expired more than 2 years ago. You must bring that identification with you to be verified when you collect your certificate of approval, if your application is successful.

New Zealand driver licence*

Number:

Version number:

Expiry date:

Passport*

Passport number:

Date issued:

Expiry date:

Nationality as shown on passport:

18+ card issued by the Hospitality Association of New Zealand*

Number:

Firearms licence issued under section 24 of the Arms Act 1983*

Number:

If your application is successful, you must collect your certificate of approval from a branch or outlet of the organisation that produces the certificates; or if there is no such organisation, from the address specified on the Licensing Authority Internet site. Please see the Licensing Authority’s Internet site for details. Complete the following if the Internet site indicates that there is an organisation producing the certificates of approval:

Preferred branch/outlet:

I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.

Full name:

Class(es) of responsible employee:

Certificate of approval number:

Expiry date:

Version number:

Conditions [if any]:

[Insert photograph]