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Internal Affairs Te Tari Taiwhenua

BDM403

Application by Donor to Access Information held on the Human Assisted Reproductive Technology Register. 

Please complete and post to HART Team, Births, Deaths & Marriages (HART, PO Box 10526, Wellington 6143).

Please attach a certified copy of an identity document belonging to the person who is making the request. 
If the information is being sent to an agent (e.g. lawyer) acting on behalf of a donor, please ensure the “Authorisation for Disclosure of Information to Agent” form is also completed. 

Benefit of counselling. 
It is strongly recommended that you consult with a counsellor of your choice before submitting this form. Counselling helps people to consider the implications of accessing information about donor offspring who have been born as a result of your donation, and contacting those people. 
Counsellors can answer questions about how others have approached the issue, and what seems to work best. Counselling may be arranged through a fertility service provider, or with an independent counsellor. 

Personal and Address Details.
Current first name(s) of donor. ^
Current surname of donor. ^
Fertility service provider (and branch, if relevant). ^
Donor identifier (if known). ^
Address information being posted to. ^
Daytime contact telephone number. ^
Email. ^

Information requested (Restrictions on disclosure of some types of information may apply).
A printout containing all or any of the following: $40.80
Information held by BDM in the Voluntary Register relating to the donor who is the subject of the application. Yes or No ^
Information about all donor offspring related to the donor (if consent to disclosure is held). Yes or No 

A printout containing the following information: $15.30 (or no extra fee, if requested with the above products).
Whether any donor offspring has or have been born and the sex of the donor offspring. Yes or No ^

Payment Details (All Fees Must be Pre-paid).

I enclose a NZ cheque/NZ money order (payable to the Department of Internal Affairs) for $ ^
or
Please debit my 
Visa Yes or No ^
Mastercard Yes or No ^
Amex Yes or No ^
for $ ^
Credit card number ^
Cardholder name and signature ^

Sections 61, 63(8) and 63(9) of the Human Assisted Reproductive Technology Act 2004.