*** 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 DENIAL Application for denial of New Zealand citizenship This application form should be completed to obtain evidence that you are not a New Zealand citizen. Please forward your application to the address at the end of the form. Allow 15 working days for processing as there is no urgent service. Each person requires a separate application form and the processing fee of NZ$112.40. Please include a photocopy of the biodata page of your current passport which records all of your personal details. Note These details should be exactly as recorded in your passport on the “bio-data” page 1. Applicant’s details Please enter your title, for example Mr, Ms, Miss, Master or Other ^ Surname ^ First name(s) ^ If your name has changed, was it by marriage, deed poll, or by any other means? Enter reason here ^ What was your previous name? ^ Town/ City of birth ^ Country of birth ^ Date of Birth (DD/MM/YYYY) ^ Are you male or female? ^ 2. Spouse’s details Name ^ Date of birth (DD/MM/YYYY) ^ Date of marriage/ civil union (DD/MM/YYYY) ^ Town/City of birth ^ Country of birth ^ 3. Parent’s details Mother - all names ^ Mother's date of birth (DD/MM/YYYY) ^ Mother's town and country of birth^ Is your mother a New Zealand citizen? Yes or no ^ Father - all names ^ Father's date of birth (DD/MM/YYYY) ^ Father's town and country of birth^ Is your father a New Zealand citizen? Yes or no ^ 4. Address and contact details Please note: This is the address that the completed certificate will be sent to. Address details Street ^ Suburb ^ Town/City ^ Province ^ Country ^ Post Code ^ Contact details Home phone ^ Work phone^ Mobile phone ^ Fax ^ Email ^ Privacy Act 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 denial 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 10-680, Wellington, New Zealand. You have a right of access to and correction of personal information you have provided under the Information Privacy Principles of the Privacy Act 2020. • 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 authorise any additional enquiries necessary for determining this application of New Zealand citizenship. 5. Applicant signature Name ^ Signed ^ Dated ^ If the applicant is under 16 years of age Name of parent ^ Signature of parent ^ 6. Fees and payment Please enclose a fee of NZ$112.40 per applicant. Please do not send cash. If you want to pay by cheque or bankdraft, please make it payable to “Department of Internal Affairs”. Please charge my credit card. State what card it is - Mastercard or Visa ^ Credit Card Number ^ Print Full name of Cardholder ^ Expiry date ^ Amount NZ$ ^ Signature ^ Print and sign. Digital signatures are not allowed Lodging an Application Completed applications or any queries concerning New Zealand citizenship can be sent to: The Citizenship Office Identity Services Department of Internal Affairs PO Box 10-680, Wellington, New Zealand Telephone: 64-4-474 8123 (outside New Zealand) 0800 22 51 51 (New Zealand only) Fax 64-4-382 3561 Email staykiwi@dia.govt.nz Applicants who live outside New Zealand may lodge their application at some New Zealand High Commissions, Embassies or Consulates.