Application form

Certificate of Conduct for Natural

Persons (VOG NP)
Complete the form in block letters.
When submitting your application to the municipality, you must
produce a valid identity document and pay the appropriate fee.

1 To be completed by the applicant

1.1 Applicant's details

Surname and given names

Prefix to surname and given names (in full)

Day Month Year

Place of birth Country of birth

Street and number Postal code

Country Town/city

> Below, enter your nationality. If you have a dual or multiple nationality mention them also
Nationality/ies

Citizen Service Number:

Telephone number Email address

1.2 Applicant's signature

The applicant hereby declares that he/she has completed this form in full and truthfully, and agrees to the
content of the explanatory note on question 1.2.
Place Day Month Year

Signature

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2 To be completed by the organisation/body requiring the Certificate

2.1 Details of organisation/body

Name of organisation/body

Name of representative

Street and number Postal code and town/city:

Telephone no. Country

2.2 Purpose of the application

> If you are applying for the Certificate of Conduct in order to obtain a visa, license, taxi driver’s permit etc.,
enter this information under 'Other'.

Employment

Job (to which the application relates; e.g. teacher, cleaner, transport manager)

Description of tasks (if possible, enclose a job description)

Other purpose

Description (e.g. taxi driver’s permit, visa/emigration, operating license)

2.3 Specific screening profile

Are you applying for the Certificate in connection with one of the jobs or purposes mentioned below?

> For more information on the risks associated with these jobs or purposes, go to www.justis.nl.

No. continue with question 2.4

Yes, the following job/purpose: (NB: Check only one box)

01 Political office holder

06 Visa and emigration

18 Housing permit
This screening profile may be used only under 'Wet bijzondere maatregelen grootstedelijke problematiek'

25 (Special) enforcement officer

40 Holiday host family and adoption

45 Health care and welfare of people or animals

50 Operating license
This screening profile may be used only if the municipality is the body requiring the Certificate and you
are applying for a Certificate in order to obtain an operating license for a catering establishment

55 Legal services

60 Education
This screening profile is applicable to anyone working in an educational institution

65 Taxi industry; taxi driver's permit

This screening profile may be used only if Kiwa Register BV is the organisation requiring the Certificate

70 Taxi industry; operator's license

This screening profile may be used only if Kiwa Register BV is the organisation requiring the Certificate of
Conduct
Initial/stamp of organisation/body

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75 Family supervisor, probation officer, child welfare investigator, social worker

80 Sworn interpreters/translators
This screening profile may be used only if the Legal Aid Council is the body requiring the Certificate.

85 Membership of shooting club

95 Financial services

96 Unknown employment
This screening profile may be used only for recruiting staff with an unknown employment

2.4 General screening profile

> Check where applicable

Screening will be based on the features of the job you have checked, so it is important to make sure that the features
checked correspond to the job/tasks or other purpose concerned.

> For more information on job features, go to www.justis.nl.

Information
11 Being authorised to consult and/or process data in computer systems

12 Handling sensitive/confidential information

13 Having knowledge of security systems, control mechanisms and verification processes

Money
21 Handling cash, transferable money and/or (digital) securities

22 Having budgetary authority

Goods
36 Monitoring production processes

37 Having access to goods

38 Having access to materials, property, objects etc. that, if used inappropriately or incorrectly, pose a risk to people
and/or animals

Services
41 Providing services (advice, security, cleaning, catering, maintenance, etc.)

43 Services in individual living environment

Business transactions
53 Making decisions on offers (conducting negotiations and concluding contracts) and awarding contracts

Processes
61 Maintaining/converting/operating production or other machinery and/or devices, vehicles and/or aircraft

62 Transporting and/or delivering goods, post and packages otherwise than via an in-company transport system

63 Transporting passengers

Management
71 Managing people and/or (part of) an organisation

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Persons
> If you check ‘Persons’ as a risk area, there must be a difference in power between the persons concerned.
It is not about dealing with colleagues.

84 Being responsible for the care of minors

85 Being responsible for the care of persons requiring assistance such as the aged and the disabled

86 Childcare (This should only be used in combination with number 84)

Initial/stamp of organisation/body

2.5 Special circumstances

> Indicate any special circumstances in connection with the application.

The location where you do your job may be relevant to the application's assessment. For instance, if you
provide cleaning services at a childcare centre, the assessment will be conducted differently than if you do so in
an office.

No (continue with the next question)

Yes (please explain)

2.6 Signature on behalf of the organisation/body

On behalf of the organisation/body, the undersigned hereby declares that he/she has completed this form in full and truthfully.

Place Day Month Year

Signature of representative

Stamp of organisation/body

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3. To be completed by the municipality

Application number

Any special remarks No (continue with the next question)

Yes (please explain)

Continue processing the No (continue with the next question)

application
Yes (please explain)

COVOG consulted about No (continue with the next question)

admissibility
Yes (please explain)

Application form has been completed in full, and applicant's identity has been verified.

Name of municipal officer

Initials of municipal officer

Municipality
Place Day Month Year

Place and date

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Explanatory notes

For persons completing the application form for a Certificate of Conduct for Natural Persons (VOG NP)

Complete the form with care and without spelling mistakes. Some of the information you submit will be
automatically copied to the Certificate of Conduct.

1. To be completed by the applicant

1.1 Applicant's details

Surname Enter your surname.

Place of birth Indicate the town/city where you were born, as it was called at the time of your birth.
Country of birth If you were born outside the Netherlands, indicate the country where you were born, as it
was called at the time of your birth.

1.2 Applicant’s signature

By signing this application form you declare that you agree that, where applicable, information will be requested
from the criminal justice records of the country of which you are a national and that the information in question
may be used in assessing your application.

2. To be completed by the organisation/body requiring the Certificate

2.1 Details of organisation/body

Name of representative: enter the name of the person representing the organisation/body named in this application

2.2 Purpose of the application

Job The job in connection with which you are applying for the Certificate.
Description of tasks Describe the tasks and responsibilities that come with the job. You may omit this description
if you enclose a job description.
Other purpose Not all applications for a Certificate are accepted for processing. An application for a
Certificate in order to get married in the Netherlands, for instance, will not be accepted for
processing. For more information on the conditions for processing an application, contact the
Central Organisation for Certificates of Conduct (COVOG) (for contact details, go to
www.justis.nl).

2.3 Screening profile

If you have not checked a screening profile box in question 2.3, you must check the job/task features or another
purpose in question 2.4. The COVOG may cancel an application if the organisation/body requiring the Certificate has
not checked a general or specific screening profile.

Important!
As the organisation/body requiring the Certificate, you are a link in preventing fraud. By initialing the application
form at the bottom of each page, you will be helping prevent fraud. You are also responsible for verifying the
authenticity of the Certificate you receive. For more information on this subject, go to www.justis.nl.

A pre-printed signature on a Certificate is sometimes not enough because an original signature is

required, for instance in cases of international adoption, when you are obliged to guarantee to the
foreign authorities that the signature is authentic. When you submit your application, you can ask the
municipal officer to include as a special remark that your Certificate must be provided with an original
signature.

January 2017