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Application pack for trans-tasman mutual recognition arrangement

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CONSENT TO DISCLOSURE OF INFORMATION<br />

Licensing & Vetting Service Centre<br />

Police National Headquarters<br />

Note:<br />

1. Please send this <strong>for</strong>m to the Authority with your application.<br />

2. Do not send this directly to the Police.<br />

I,.....................................................................................................................................................................................<br />

(Surname)<br />

(First Names)<br />

.......................................................................................................................................................................................<br />

(Maiden or any other names used)<br />

Sex...............(M/F)<br />

Nationality.........................................................................................................................<br />

Date of birth.........................................<br />

Place of birth.............................................................................................<br />

Residential Address......................................................................................................................................................<br />

Suburb................................................................<br />

City..............................................................................................<br />

NZ Driver Licence number .......................................................<br />

Card Version Number (5b)................<br />

Expiry Date (dd/mm/yyyy) …..…../…..…../……….<br />

authorise disclosure to the Real Estate Agents Authority by New Zealand Police of ANY in<strong>for</strong>mation that may<br />

be held by Police, including any interaction I have had with Police in any context or any in<strong>for</strong>mation received<br />

by Police. I understand that this is not limited to conviction in<strong>for</strong>mation.<br />

Where that in<strong>for</strong>mation relates to any record of criminal convictions I might have, I understand that it will<br />

automatically be concealed if I meet the eligibility criteria stipulated in Section 7 of the Criminal Records<br />

(Clean Slate) Act 2004.<br />

Vetting can only be carried out with the consent of the applicants, as evidenced by the signature and date as<br />

follows:<br />

Signed ............................................................................... Date ......................................................................<br />

Office Use only<br />

COMMENTS OF THE NEW ZEALAND POLICE<br />

3

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