*** Transcriber's Note: Please set your voice synthesiser to read most punctuation. When you encounter the caret sign (^) at the end of a line, please enter the applicable information, if necessary. *** The Department of Internal Affairs Te Tari Taiwhenua dcs: certcp You will need to print and sign this form. Application for certified copy of descent registration certificate Name Show names in full from full birth certificate of the person being registered unless name has been legally changed, for example, by marriage, deed poll or statutory declaration. Title, for example, Mr, Mrs, Ms, Miss, Master or Other ^ Family or Last names ^ Given or First names ^ Do you have other names, for example, birth name, unmarried name, name change, alias, English names if used etc. Yes or no ^ If your name has changed, explain why. For example, marriage or civil union, declaration, common use, adoption or other ^ If other, please explain ^ Identification Birthdate (DD/MM/YYYY) ^ Town or City of Birth ^ Country of birth ^ Date of registration (DD/MM/YYYY) ^ Place of registration ^ Sex Are you male or female? ^ Parent’s details Name as it appears on New Zealand birth certificate or New Zealand citizenship certificate unless it has been legally changed, for example, by marriage, deed poll or statutory declaration. Mother Family or Last names ^ Given or First names ^ Other Names, for example, birth name, unmarried name, name change, alias, English names if used, etc. ^ Birthdate (DD/MM/YYYY) ^ Town or City of Birth ^ Country of birth ^ Date of marriage or civil union ^ Father Family or Last names ^ Given or First names ^ Other Names, for example, birth name, unmarried name, name change, alias, English names if used, etc. ^ Birthdate (DD/MM/YYYY) ^ Town or City of Birth ^ Country of birth ^ Address PLEASE NOTE that this is the address that the completed certificate will be sent to. Street ^ Suburb ^ Town or City ^ Province ^ Country ^ Post Code ^ Telephone Home ^ Mobile ^ Work ^ Fax ^ Email ^ Privacy Act Authorised information matching programmes Information held by Citizenship can be used in authorised information matching programmes by the Electoral Enrolment Centre, the Department of Internal Affairs, the Inland Revenue Department, the Land Transport New Zealand, the Ministry of Education, the Ministry of Social Development and the Workforce Group (Immigration Services) as authorised by statute. Details are available on the Internal Affairs website - www.dia.govt.nz or call 0800 22 5151. Collection and use of information provided in support of application This application form requires you to produce certain information in support of this application. The decision to supply the information is voluntary. If you do not produce sufficient information to enable a confirmation of New Zealand citizenship to be determined, the application will be declined. The collection of this information is required to see if the requirements of the Citizenship Act 1977 are met, to process the application and for other lawful purposes. The information you provide in this form is collected and held by Department of Internal Affairs, PO Box 10680, Wellington, New Zealand and the Ministry of Foreign Affairs and Trade. You have a right of access to and correction of personal information you have provided under the Information Privacy Principles of the Privacy Act 1993. I declare that the statements made in this application are to the best of my knowledge true, complete and correct. I understand that if false information has been provided any citizenship certificate issued on the basis of that information may be cancelled and the matter referred to the New Zealand Police. I confirm that I have read and understood the statement above relating to privacy. I consent to information being obtained about me for the purposes of determining eligibility with respect to this application by an authorised information matching programme in accordance with section 78A of the Births, Deaths and Marriages Act 1995. I authorise any additional enquiries necessary for determining this claimant’s eligiblity for the registration of New Zealand citizenship. Applicant If applicant is under 16 years of age, the parent must sign this form. Name ^ Signed ^ Dated (DD/MM/YYYY) ^ Lodging an Application Completed applications or any queries concerning registration of New Zealand citizenship by descent can be sent to the Citizenship Office in Wellington. Applicants who are residing outside New Zealand may lodge their application at some New Zealand High Commissions, Embassies or Consulates. Lodging an application The Citizenship Office Department of Internal Affairs PO Box 10680 Wellington New Zealand Queries Phone when outside New Zealand: +64 4 474 8123 Freephone in New Zealand only: 0800 22 51 51 Fax: +64 4 382 3561 Email: staykiwi@dia.govt.nz Website: www.govt.nz/citizenship Fees and payment Please enclose a fee of NZ$112.40 per applicant. Please do not send cash. For cheque or Bank draft, please make payable to Department of Internal Affairs. Credit card Are you using Mastercard or Visa? ^ Expiry date (DD/MM/YYYY) ^ Credit Card Number ^ Full name of Cardholder ^ Amount in New Zealand dollars ^ Do you want to charge the return courier fee to your credit card? Yes or no ^ Signature ^ Proof of identity This form must be completed by your witness in their own handwriting. You must give them 2 identical passport size photos of you. Both photos must be the same in all aspects - 2 prints from the same negative - taking care they are not damaged by staples, pins, paperclips, folding or ink. The Photos must be: • recent, less than 6 months old • a full front, close up view of the head and shoulders with the head covering 70% to 80% of the photograph • taken with a neutral expression (not laughing or frowning) with your mouth closed. Show you looking straight at the camera, and your head not tilted. Show your eyes open and clearly visible, and no hair in your eyes • without sunglasses. Tinted prescription glasses may be worn as long as eyes are still visible • a true image and not altered in any way • clear, sharp and in focus • with a plain light coloured background (not white) • of good quality colour and on high quality paper, with no ink marks on the image (no ink jet printers) • 45mm by 35mm in size. Do not trim your photos. Contact the Citizenship Office if you require further information on photographic image requirements. The witness must complete this section in their own handwriting. Can you act as a witness? To act as a witness, you must be aged 16 years or over and not be a relative or partner and not live at the same address and EITHER have known the applicant for more than 12 months OR since birth if the child is under 12 months old. Personal details of the witness Surname or family name ^ Given or first names ^ Occupation ^ Date of Birth (DD/MM/YYYY) ^ Address Street ^ Suburb ^ Town or City ^ Country ^ Telephone Home ^ Mobile ^ Work ^ Fax ^ Email ^ Declaration I declare that I have known enter applicant’s full name ^ for Years enter number of years ^ or Months enter number of months ^ and can confirm their identity. I have written the full name of the applicant, dated and signed my own name on the back of 1 photograph. Signature of Witness ^ Date (DD/MM/YYYY) ^ This is the end of the Witness section.