Full legal name:

Nature of applicant (incorporated or otherwise):

If unincorporated, attach proof of identity and of New Zealand citizenship or permanent residency.

If incorporated, attach evidence of incorporation in New Zealand and provide full names and dates of birth of each member of management.

Physical address of all permanent offices in New Zealand:

Physical address for delivery and service of notices:

Postal address (if different from physical address):

Email address:

Telephone number:

Fax number:

Full name:

Title:

Email address:

Direct-dial telephone number:

Mobile telephone number:

Fax number:

Please provide details of any limitation on the scope that would apply to building control function work that would be undertaken if registration is granted.

For the applicant and each member of management please provide details of—

• any prior professional misconduct, such as disciplinary proceedings initiated or action taken by a professional institute or association; and

• any civil claims made against that person in relation to contractual performance or tortious liability; and

• any New Zealand or overseas convictions, or pending proceedings, in relation to dishonesty offences (such as fraud or forgery) or offences under enactments relating to building; and

• any prior suspension, cancellation, or refusal of, or lapse in, status as—

  • a building certifier under the Building Act 1991; or

  • an accredited or registered building consent authority in New Zealand; or

  • any overseas equivalent building control authority; and

• any prior building control experience in New Zealand or overseas.

Please provide evidence that the applicant holds a current accreditation from a building consent accreditation body appointed under section 248 of the Building Act 2004.

Please provide evidence that the applicant has adequate means to cover any civil liabilities that may arise in the performance of the functions of a building consent authority—including insurance policies or any other arrangements that provide for effective consumer protection (for example, by giving a bond or having a guarantor).

Please confirm that the applicant would have no conflicts of interest in fulfilling the role of a building consent authority and how the applicant would act to avoid such conflicts.

When you have completed the rest of this form, and all the supporting information has been prepared and attached, please take it to a Justice of the Peace, a Solicitor, or the Registrar or Deputy Registrar of the court to be witnessed. The declaration must be completed by a person who has legal authority to sign on behalf of the applicant. A significant penalty, including a term of imprisonment of up to 3 years, may be imposed under the Crimes Act 1961 for making a false declaration.

I, [full name and designation], solemnly and sincerely declare that—

*I am the applicant for which this licence application is being made

*I am authorised to make this application on behalf of the applicant

I have made all reasonable inquiries and the information contained in this application is true and correct to the best of my knowledge and belief and is accompanied by all relevant information known to the applicant.

I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.

Signature:

Full name:

Declared at [place] on [date].

Witness signature:

Witness name:

Witness designation:

Full legal name of the territorial or regional authority:

Physical address of the territorial or regional authority for delivery or service of notices:

Postal address (if different from physical address):

Telephone number:

Fax number:

Email address:

Full name:

Title:

Email address:

Direct-dial telephone number:

Mobile telephone number:

Fax number:

Please provide evidence that the applicant holds a current accreditation from a building consent accreditation body appointed under section 248 of the Building Act 2004.

When you have completed the rest of this form, and all the supporting information has been prepared and attached, please sign and date the form and submit the form to the Department of Building and Housing. The application may only be signed by a person who is authorised to sign on behalf of the territorial or regional authority.

Signature of person authorised to sign this application on behalf of the territorial or regional authority:

Full name of signatory:

Designation of signatory:

Dated at [place] on [date].