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    Criminal Check Form

    Uploaded by

    Sagar Kashyap
    This 3 page document is a request form for a third party to obtain an individual's criminal convictions from the New Zealand Ministry of Justice. It collects information about the subject, including identification details and consent to release information. It also collects contact information about the third party making the request. The subject signs to authorize the Ministry of Justice to release their criminal conviction information to the third party for purposes such as pre-employment vetting, insurance claims vetting, or traffic convictions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Criminal Check Form

    Uploaded by

    Sagar Kashyap
    54 views3 pages
    This 3 page document is a request form for a third party to obtain an individual's criminal convictions from the New Zealand Ministry of Justice. It collects information about the subject, including identification details and consent to release information. It also collects contact information about the third party making the request. The subject signs to authorize the Ministry of Justice to release their criminal conviction information to the third party for purposes such as pre-employment vetting, insurance claims vetting, or traffic convictions.

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    This 3 page document is a request form for a third party to obtain an individual's criminal convictions from the New Zealand Ministry of Justice. It collects information about the subject, including identification details and consent to release information. It also collects contact information about the third party making the request. The subject signs to authorize the Ministry of Justice to release their criminal conviction information to the third party for purposes such as pre-employment vetting, insurance claims vetting, or traffic convictions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    54 views3 pages

    Criminal Check Form

    Uploaded by

    Sagar Kashyap
    This 3 page document is a request form for a third party to obtain an individual's criminal convictions from the New Zealand Ministry of Justice. It collects information about the subject, including identification details and consent to release information. It also collects contact information about the third party making the request. The subject signs to authorize the Ministry of Justice to release their criminal conviction information to the third party for purposes such as pre-employment vetting, insurance claims vetting, or traffic convictions.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    IN-CONFIDENCE WHEN COMPLETED

    Priv/F2
    For Office Use Only
    Privacy Unit Ministry of Justice National Office P O Box 2750 WELLINGTON

    MoJ Request Number

    REQUEST BY THIRD PARTY UNDER THE OFFICIAL INFORMATION ACT 1982 FOR A COPY OF AN IND IVIDUAL'S CRIMINAL CONVICTIONS HELD ON THE MINISTRY OF JUSTICE 'S COMPUTER SYSTEMS

    SECTION 1: SUBJECT'S AUTHORITY TO RELEASE INFORMATION TO A THIRD PARTY


    I hereby authorise the Privacy Unit, Ministry of Justice, to release a copy of my personal information, to the undersigned Third Party, for the purpose of: Tick the report required: Pre-employment vetting All convictions report Traffic Convictions Report

    Insurance Claims vetting

    Signature of subjec t and date

    Other (specify)

    X
    I wish to receive a copy of the information provided to the Third party.

    X
    Yes / No

    SECTION 2: THIRD PARTY DETAILS


    Third Party Name Details
    Full Name of Thir d Party

    Full name and address of the person or agency the third party is acting for (if applicable)

    Third Party Reference Number (if applicable)

    Third Party Address Details


    P.O. Box or Street Address

    Signature of Third Party

    X
    Suburb

    City

    State / Province

    Post Code

    Country

    The term "subject" refers to the person whose criminal convictions is being requested. The term "third party" refers to the requestor or ultimate intended recipient, such as an employer, insurance company, credit agency et cetera.

    The Ministry of Justice will process this request as soon as is reasonably practicable, and in any case no later than 20 working days from receipt of this application. This application and associated letters and reports will be disposed of three months after processing the response.
    Page 1 of 3 Form continues overleaf

    SECTION 3: SUBJECT'S DETAILS (Please print in pen)


    Personal Details
    Surname

    Priv/F2
    First Name

    Middle Names (separate b y comma)

    Date of Birth (DD/MM/YYYY)

    Place of Birth

    Gender (Male / Female / Indeterminate)

    Previous Names - Maiden Name , Aliases


    Surname

    First Name

    Middle Names (separate b y comma)

    Postal Address
    P.O. Box or Street Address

    Current Residential Address Street Address

    Suburb

    Suburb
    City

    City

    State / Province

    State / Province
    Post Code
    Country
    Daytime Phone Number

    Post Code

    Country

    Home Phone Number

    Previous Two Residential Addresses


    Street Address

    Fax Number

    Street Address

    Suburb
    City

    Suburb
    City
    State / Province
    Post Code
    Country
    Page 2 of 3 Form continues overleaf

    State / Province
    Post Code
    Country

    SECTION 3: SUBJECT'S DETAILS (continued)


    Subject's Identification

    Priv/F2

    Please attach a photocopy of the subject's identification. The identification may be a Driver Licence OR if subject does not hold a driver licence, a Passport. If subject has neither, the subject will need to complete Section 4.

    Driver Licence

    Passport

    SECTION 4: PROOF OF IDENTITY ONLY TO BE COMPLETED IF SUBJECT DOES NOT HAVE A DRIVER LICENCE OR PA SSPORT Subject to ask someone who can confirm their identity to fill in th is section The person who identifies sub ject must: - have known subject for more than 12 months - be aged 18 years or over - have a day time phone number Surname - not be a relative - not live at the same address - be contactable during normal business hours

    First Name

    Middle Names (separate b y comma)

    Street Address

    Daytime Phone Number

    Suburb

    Home Phone Number

    City

    State / Province

    Fax Number

    Post Code

    Country

    I declare that I have per sonally known: Surname

    First Name

    Middle Names (separate b y comma)

    Signature of identifier

    for

    years and vouch for his/ her identity

    If subject is unable to get someone to complete Section 4, they must complete a statutory declaration. The relevant form can be obtained from the local District Court or by contacting the Privacy Unit on 04 918 8800.

    Page 3 of 3

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