Photo ID Card Application Form - Port Nelson

PHOTO IDENTITY CARD APPLICATION
CONSENT FORM
A. CONDITIONS OF USE FOR ALL PHOTO IDENTITY CARDS
1. The applicant must comply at all times with the Port Nelson Ltd Standard Terms and conditions, the
Health and Safety policy, as well as the Port Security requirements.
2. The card may only be used in the course of the holder’s authorised duties in the port area.
It does not constitute an authority to enter or remain in the port Restricted Area at any other
time.
3. The card must be presented for inspection on demand, at anytime the card holder is within the Port
Nelson Ltd Restricted Area.
4. Loss of card is to be reported immediately to the Port Nelson Ltd Security Gatehouse (Carkeek Street,
Port Nelson, Ph 548 2099).
5. The card must be surrendered on expiry, transfer or termination of present duty, or on the request of
Port Nelson Ltd’s Shipping Services Manager or other staff under his designation.
6. The card is NOT transferable and can only be used by the person to whom it is issued, when that
person is on authorised business within the Port Nelson Restricted Area.
7. The applicant acknowledges that the holder of a card, the holder’s belongings, and holder’s vehicle
may be subject to a search by Security Personnel and/or Police and Border Control agencies before
entering, while within or when leaving the Port Nelson Restricted Area.
8. The card remains the property of Port Nelson Ltd.
B. The card holder or their employer agrees to pay Port Nelson Ltd the set up fee for the production of the
card.
C. I further acknowledge that failure to consent to the collection of this personal information may result in
Port Nelson Ltd. declining to issue a Port Nelson Ltd Photo Identity Card.
D. Under the Privacy Act 1993, the personal information collected by Port Nelson Ltd is for the sole purpose of
security clearance and the issue or otherwise of a Port Nelson Ltd Photo Identity Card and will be held by
Port Nelson Ltd PFSO. The person to whom the information relates has the right to require access to this
personal information and request its correction as set out in the Act.
The preceding information has been noted and agreed to:
Applicant’s name: Signature: Date:
CAUTION
It is an offence to knowingly provide false information to Port Nelson Ltd.

PHOTO IDENTITY CARD APPLICATION FORM
A. APPLICANT’S INFORMATION
(To be completed by the Applicant only after signing the consent form)
Surname/Family Name:
First Name:
Middle/Other Names:
Residential Address:
Telephone: Home:
Business:
Driver Licence No:
Expiry Date:
Mobile:
Email:
Date of Birth:
Pager:
Country of Citizenship:
Employed by (Company Name):
Applicant’s Positon/Title:
Applicant’s Signature:
N.B: If the Application is for an ID Card and Access Card, a Pin Number is required.
B. EMPLOYER CERTIFICATION
I
of
(Full name)
(Organisation)
Confirm that the information supplied in Section A (Applicant’s Information) is correct to
the best of my knowledge and request that a Port Nelson Ltd Photo Identity Card be issued
to:
(Full name)
I undertake to notify Port Nelson Ltd. of any changes to the supplied particulars, and to
recover and return the card to Port Nelson Ltd. prior to the applicant leaving our employ,
or upon transfer of the applicant to a position which does not require retention of the
Photo Identity Card.
Business Address:
Business Phone:
Fax:
Signature:
Position:
Date: