Basic form – Visit/Work/Study
1-Details as shown in passport
Preferred Title (Mark with a cross) Mr ___ Mrs ___ Ms ___ Miss ___ Dr ___
First Name (As Shown In Passport)
Middle Name (If You Have)
Family Name (As Shown In Passport)
Other Names You Are Known By Or Have
Ever Been Known By
Date Of Birth (DD/MM/YYYY)
Gender (Mark with a cross) Male _____ Female _____
Country Passport Issued
Town/City Passport Issued
Passport Number
Passport Expiry Date
Current Visa Type
Current Visa Expiry Date (dd/mm/yyyy)
Birth Place : Country
Birth Place : State
Birth Place: Town
Overseas Address
National ID Number
Single ___ Married ___ Divorced___ Separated ___
Partnership Status
Partner ___ Engaged ___ Widowed ___ Defacto ___
2-Contact Details (Current Residential Address)
Flat No
Entrance No
Building No
Street No And Name
Suburb
Post Code
Telephone (Landline)
Telephone (Mobile)
Email
1
3-Principal Applicant’s Family Details - Partner information
Full Name
Gender
DOB
Partnership Status
Country
Occupation
Birth Place : Country
Parents, siblings and children (including half, step and adopted brothers and sisters)
Relationship to Country of
Full name DOB Partnership Status
you Residence
4-Friends, Relatives, or Contacts in New Zealand
First Name
Middle Name
Last Name
Address Line 1
Address Line 2
Relationship
Telephone
Email
DOB
2
5-Financial Support Details (For Student Visas)
A third Party (relative, friend or a supporting organisation) is providing a financial undertaking
Yes ____ No ____
You have sufficient funds equivalent to NZ $15,000 for a full year of study, or NZ $1,250 per month
Yes ____ No ____
You have sufficient funds to pay your tuition fee.
Yes ____ No ____
You are fully funded by the award of a full scholarship.
Yes ____ No ____
You have sponsorship for temporary entry by an acceptable sponsor.
Yes ____ No ____
6-Financial Support Details (For Work Visa/Visitor Visa)
How will you be financially supporting your stay in New Zealand?
You have sufficient funds to support your stay
Yes ____ No ____
Your sponsor is financially supporting your stay?
Yes ____ No ____
Your employer or another third party is supporting your stay?
Yes ____ No ____
7-Educational History
Qualification
Start Date
End Date
Institute Name
Address
Qualification
Start Date
End Date
Institute Name
Address
3
8-Health and Character
If You Have Ever Been Convicted Of An Offence (Including A Traffic Offence) Please Provide Details
Yes ____ No ____ Details_________________________________________________________
______________________________________________________________________________
Are you, or is anyone included in this application, currently is under investigation for any offence in any
country?
Yes ____ No ____
Have you, or has anyone included in this application, ever been removed or deported from any
country, including NZ?
Yes ____ No ____
Have you, or has anyone included in this application, ever been refused entry from any country,
including NZ?
Yes ____ No ____
Do you, or does anyone included in this application have any medical condition that requires, or may
require, Hospital care during your stay in NZ?
Yes ____ No ____
Are you submitting your medical certificate with this visa application? if yes, provide code
NZER code _______________
When did you submit your last General Medical (dd-mm-yy)?
Date _________________
When did you submit your last X-ray (dd-mm-yy)?
Date _________________
When did you submit your Police certificate(dd-mm-yy)?
Date _________________
Have you previously applied for a visa for New Zealand?
Yes ____ No ____ If Yes Then Client Number _________________
Are you pregnant?
Yes ____ No ____ Not applicable ____
Do you have tuberculosis (TB)?
Yes ____ No ____
Do you have any Renal Disease?
Yes ____ No ____
If you have TB or Renal Disease please provide details________________________________________
Have you ever had a blood or blood product transfusion?
Yes____ No_____
4
Have you ever used intravenous drugs?
Yes____ No____
Have you ever participated in, or been exposed to, any activity which may have exposed you to a
serious infectious disease (such as HIV, or hepatitis B or C)?
Yes____No____
9- Work History
Job Title
Employer Name
Employer Address
Start Date
End Date
Job Title
Employer Name
Employer Address
Start Date
End Date
Job Title
Employer Name
Employer Address
Start Date
End Date
