Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698835102089.pdf (New Zealand)
2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Anand Satyanand, Governor-General Order in Council At Wellington this 28th day of March 2011 Present: His Excellency the Governor-General in Council Pursuant to section 114 of the Private Security Personnel and Private Investigators Act 2010, His Excellency the Governor-General, acting on the advice and with the consent of the Executive Council, makes the following regulations.
Contents Title Commencement Interpretation Applications for licences Applying for individual licence Applying for company licence Notice of intention to apply for licence Notice of intention to apply for licence Page 2 2 2 2 2 3 1 Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Issuing licences Form of individual licence Form of company licence Applying for approval of subsequent company officers Applying for approval of person to act as company officer after licence granted Application for certificate of approval Applying for certificate of approval Issuing certificates of approval Form of certificate of approval Schedule Forms Regulations 3 3 3 3 3 4 Title These regulations are the Private Security Personnel and Pri- vate Investigators (Forms) Regulations 2011.
Commencement These regulations come into force on 1 April 2011.

Interpretation In these regulations, unless the context otherwise requires, Act means the Private Security Personnel and Private Investigators Act 2010.

Applications for licences Applying for individual licence An application under section 24 of the Act by an individual for a licence must be in form 1 of the Schedule.
Applying for company licence An application under section 25 of the Act by a company for a licence must be in form 2 of the Schedule.
r 1 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 r 11 Notice of intention to apply for licence Notice of intention to apply for licence An applicant for a licence must provide the notice of intention to apply for a licence under section 27(2) of the Act to the Licensing Authority for publication on its Internet site in form 3 of the Schedule.
Issuing licences Form of individual licence A licence issued under section 34 of the Act to an individual must be in form 4 of the Schedule.

Form of company licence A licence issued under section 34 of the Act to a company must be in form 5 of the Schedule.
Applying for approval of subsequent company officers Applying for approval of person to act as company officer after licence granted An application under section 40 of the Act for approval of a person who was not an officer of a company at the time when the application for the company’s licence was granted to act subsequently as an officer of the company must be in form 6 of the Schedule.
Application for certificate of approval Applying for certificate of approval An application under section 46 of the Act for a certificate of approval must be in form 7 of the Schedule.

Issuing certificates of approval Form of certificate of approval A certificate of approval issued under section 54 of the Act must be in form 8 of the Schedule.
3 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Forms Form 1 Application by individual for licence Section 24, Private Security Personnel and Private Investigators Act 2010 2011/73 rr 4–11 Personal details First name(s): Middle name(s): Last name(s): Gender: Occupation: Date of birth: Contact details Full residential address: Full address at which documents relating to the application may be served on you, if different from residential address: Daytime contact number: Home telephone number [optional]: Mobile number [optional]: Fax number [optional]: Email address [optional, unless applying by electronic means]: Other name(s) If you are known by, or have ever been known by, another name, provide details.
First name(s): Middle name(s): Last name(s): Previous licence or certificate of approval If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private 4 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 1—continued Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.
Licence number: Certificate of approval number: Place(s) of business Provide the full address of every place of business from which you propose to carry on the business or businesses to which the applica- tion relates.

Principal place of business Specify which of the addresses given under “Place(s) of business” is your proposed principal place of business.

Class(es) of business Specify the particular class or classes of business that you propose to carry on.
Private investigator Security technician Security consultant Confidential document destruction agent Property guard Personal guard Crowd controller Grounds of disqualification under section 62 Note: Section 62 of the Private Security Personnel and Private In- vestigators Act 2010 lists certain grounds that may disqualify you from being granted a licence or certificate of approval.
However, if you answer that you have met any of the grounds of disqualification listed below, you may provide evidence to the Licensing Authority with your application relating to your character, circumstances, or background.

The Licensing Authority may still grant your applica- tion, but only if the Authority is satisfied that you are suitable to carry on the class or classes of business to which the application relates.
5 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 1—continued Please note that no refund is payable if your application is unsuc- cessful.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.
I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).
I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an of- fence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an of- fence under section 10, 11, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.
I have/have not*, within the past 7 years, been convicted of an of- fence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an of- fence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.
6 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 1—continued I have/have not*, within the past 7 years, been convicted of an of- fence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an of- fence of violence, as defined in section 4 of the Private Security Per- sonnel and Private Investigators Act 2010.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certifi- cate of approval or employing or engaging a person without a rele- vant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.

I do/do not* hold a licence or certificate of approval that has been suspended.
I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Pri- vate Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval).
[You must provide proof of meeting those requirements with this applica- tion.]

I have not/have*, within the past 5 years, had 12 months’ relevant ex- perience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

[You must provide details of relevant experience with this application.]

*Select one.
*Select one.

Convictions and orders outside New Zealand Note: Section 24 of the Private Security Personnel and Private In- vestigators Act 2010 also requires that you specify these matters.
You may provide further information in support of your application (for example, evidence of your character, circumstances, or background) if you have specified a conviction or order as follows: 7 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 1—continued I have/have never* been convicted outside New Zealand of an of- fence.
I have/have never* had an order imposed in relation to myself by any court or tribunal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

*Select one.
*Select one.

Applying for temporary certificate of approval If you wish to work, while your application for a licence is being processed, for a licensee as a responsible employee of a class that corresponds to the class or classes of private security business that you propose to carry on if your application for a licence is successful, you may be eligible for a temporary certificate of approval.

This will incur an additional fee.

I wish/do not wish* to apply for a temporary certificate of approval.
*Select one.

If you wish to apply for a temporary certificate of approval and are currently employed, you must supply the following employment de- tails: Name(s) of any current employer(s): Identification details Note: Only the forms of photo identification listed below are ad- equate to verify your identity.

You must provide details of one of the forms of identification.

The form of identification must not have ex- pired more than 2 years ago.
You must bring that identification with you to be verified when you collect your licence and identification badge, if your application is successful.
New Zealand driver licence* Number: Version number: Expiry date: Passport* Passport number: 8 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 1—continued Date issued: Expiry date: Nationality as shown on passport: 18+ card issued by the Hospitality Association of New Zealand* Number: Firearms licence issued under section 24 of the Arms Act 1983* Number: *Select one and complete its details.
Collecting licence If your application is successful, you must collect your licence and identification badge from a branch or outlet of the organisation that produces the licence; or if there is no such organisation, from the address specified on the Licensing Authority Internet site.

Please see the Licensing Authority’s Internet site for details.
Complete the following if the Internet site indicates that there is an organisation producing the licence: Preferred branch/outlet: Consent and certification I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.
Date: Signature: Name: [print name] 9 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 1—continued Notes 1 This application must be sent to the Private Security Personnel Licensing Authority, together with the prescribed fee, and any supporting documents, including— (a) a photograph that meets the requirements prescribed in the Private Security Personnel and Private Investigators Regulations 2011; and proof of compliance with any prescribed requirements for competency, knowledge, and skills.
(b) 2 Section 105 of the Private Security Personnel and Private In- vestigators Act 2010 provides that a person who is required to provide information to the Licensing Authority and gives false information knowing that it is false or being reckless as to whether it is false is liable on summary conviction to a fine not exceeding $20,000.
10 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 2 Application by company for licence Section 25, Private Security Personnel and Private Investigators Act 2010 Applicant details Company registered name: Company trading name: Company registration number: Current number of company officers: Previous licence or certificate of approval If the company has previously held a licence under the Private In- vestigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide the licence number.
Licence number: Place(s) of business: general Provide the full address of every place of business from which the company proposes to carry on the business or businesses to which the application relates.

Registered office of company Specify the address of the company’s proposed registered office.

Contact details Provide the contact details of the person the Licensing Authority can contact regarding this application.
Name: Daytime contact number: Home telephone number [optional]: Mobile number [optional]: Fax number [optional]: Email address [optional, unless applying by electronic means]: 11 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 2—continued Class(es) of business Specify the particular class or classes of business that the company proposes to carry on.
Private investigator Security technician Security consultant Confidential document destruction agent Property guard Personal guard Crowd controller Other business carried on by company Describe the nature of all other business carried on or proposed to be carried on by the company.
Nature of business: Grounds of disqualification for company under section 63 Note: Section 63 of the Private Security Personnel and Private Inves- tigators Act 2010 lists certain grounds that may disqualify a company from being granted a licence.
However, if you answer that any of the grounds of disqualification listed below apply, or any of the grounds of disqualification relating to company officers apply (see below), you may provide evidence to the Licensing Authority with your ap- plication relating to the suitability of the company to hold a licence.
The Licensing Authority may still grant the company a licence, but only if the Authority is satisfied that the company is suitable to carry on business in the class or classes of business to which the applica- tion relates.

Please note that no refund is payable if your application is unsuccessful.

The company has/has not*, within the past 7 years, been convicted of an offence under section 10, 11, 12, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.
The company has/has not*, within the past 7 years, been convicted of an offence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.
12 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 2—continued The company has/has not*, within the past 7 years, been convicted of an offence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.
The company has/has not*, within the past 7 years, been convicted of an offence under the Private Security Personnel and Private In- vestigators Act 2010 of operating while unlicensed or employing or engaging a person without a certificate of approval, or an offence under section 16, 343, or 52 of the Private Investigators and Security Guards Act 1974.

The company does/does not* hold a licence that has been suspended.
The company has/has not*, within the past 7 years, had a licence can- celled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.
The company has/does not have* any officer of the company who was, or is, an officer of another company (whether or not that other company is still in existence) that, within the past 7 years, had a li- cence cancelled under the Private Security Personnel and Private In- vestigators Act 2010 or the Private Investigators and Security Guards Act 1974.

*Select one.
*Select one.

Company convictions outside New Zealand Note: Section 25 of the Private Security Personnel and Private In- vestigators Act 2010 also requires that the company specifies these matters.

You may provide evidence to the Licensing Authority with the application relating to the suitability of the company to hold a licence.
The Licensing Authority may still grant the company a li- cence, but only if the Authority is satisfied that the company is suit- able to carry on business in the class or classes of business to which the application relates.

Please note that no refund is payable if your application is unsuccessful.

13 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 2—continued The company has/has never* been convicted outside New Zealand of an offence.

*Select one.
*Select one.

Company officer details Note: An officer, in relation to a company, is defined in section 4 of the Private Security Personnel and Private Investigators Act 2010.

This section of the form must be completed by every officer of the company.

First name(s): Middle name(s): Last name(s): Gender: Occupation: Date of birth: Contact details of company officers This section of the form must be completed by every officer of the company.
Full residential address: Full address for communications about this application, if different from residential address: Daytime contact number: Home telephone number [optional]: Mobile number [optional]: Fax number [optional]: Email address [optional, unless applying by electronic means]: Other name(s) This section of the form must be completed by every officer of the company.

If you are known by, or have ever been known by, another name, provide details.
14 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 2—continued First name(s): Middle name(s): Last name(s): Previous licence or certificate of approval This section of the form must be completed by every officer of the company.
If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.

Licence number: Certificate of approval number: Further grounds of disqualification under section 63, relating to company officers This section of the form must be completed by every officer of the company.
Note: Section 63 of the Private Security Personnel and Private Inves- tigators Act 2010 applies the grounds of disqualification listed under section 62 of the Act to company officers as grounds for disqualifying a company from being granted a licence.

However, if you answer that you have met any of the grounds of disqualification listed below, you may provide evidence to the Licensing Authority with your applica- tion relating to your character, circumstances, or background.
The Licensing Authority may still grant the company a licence, but only if the Authority is satisfied that the company is suitable to carry on the class or classes of business to which the application relates.

Please note that no refund is payable if the application is unsuccessful.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.
I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J 15 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 2—continued of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).
I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an of- fence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an of- fence under section 10, 11, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.
I have/have not*, within the past 7 years, been convicted of an of- fence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an of- fence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.
I have/have not*, within the past 7 years, been convicted of an of- fence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an of- fence of violence, as defined in section 4 of the Private Security Per- sonnel and Private Investigators Act 2010.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certifi- 16 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 2—continued cate of approval or employing or engaging a person without a rele- vant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.
I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Pri- vate Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.

Note: It is a ground of disqualification for a company if all of its officers meet the next 2 grounds of disqualification.
I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval).

[You must provide proof of meeting those requirements with this applica- tion.]
I have not/have*, within the past 5 years, had 12 months’ relevant ex- perience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

[You must provide details of relevant experience with this application.]

*Select one.

Convictions and orders outside New Zealand This section of the form must be completed by every officer of the company.
Note: Section 25 of the Private Security Personnel and Private In- vestigators Act 2010 also requires that you specify these matters.

You may provide further information in support of your application (for example, evidence of your character, circumstances, or background) if you have specified a conviction or order as follows: I have/have never* been convicted outside New Zealand of an of- fence.
17 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 2—continued I have/have never* had an order imposed in relation to myself by any court or tribunal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

*Select one.

Consent and certification This section of the form must be completed by every officer of the company.
I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.

Date: Signature: Name: [print name] This application must be sent to the Private Security Personnel Licensing Authority, together with the prescribed fee, and any supporting documents, including proof of compliance with any prescribed requirements for competency, knowledge, and skills.
Section 105 of the Private Security Personnel and Private In- vestigators Act 2010 provides that a person who is required to provide information to the Licensing Authority and gives false information knowing that it is false or being reckless as to whether it is false is liable on summary conviction to a fine not exceeding $20,000.
Notes 1 2 18 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 3 Notice of intention to apply for licence Section 27(2), Private Security Personnel and Private Investigators Act 2010 Applying for individual licence* Complete the following if you are applying for an individual licence: Take notice that I, [full name], of [town or city], am applying to the Private Security Personnel Licensing Authority for an individual li- cence to operate [class(es) of business].
Applying for company licence* Complete the following if you are applying for a company licence: Take notice that [registered name of company], [trading name of company if different from registered name], [company registration number], operating at [registered office of company] is applying to the Private Security Personnel Licensing Authority for the company to be licensed to operate [class(es) of business].

*Select one.
*Select one.

All notices of intention to apply for a licence must contain the follow- ing: Objections Any person who wishes to object to the granting of a licence to the applicant must give notice of the objection to the Private Security Personnel Licensing Authority not later than 1 month after the date of the publication of this notice.

No objection may be made except on one of the grounds set out in section 29 of the Private Security Personnel and Private Investigators Act 2010.
The notice of objection must state the grounds of the objection.

The Private Security Personnel Licensing Authority must serve a copy of any notice of objection on the applicant within 7 days after it has been filed with the Authority.
19 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 4 Form of individual licence Section 34, Private Security Personnel and Private Investigators Act 2010 Full name: Class(es) of business: Principal place of business: Other authorised place(s) of business: Licence number: Expiry date: Version number: Conditions [if any]: [Insert photograph] 20 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 5 Form of company licence Section 34, Private Security Personnel and Private Investigators Act 2010 Registered name: Class(es) of business: Registered office: Other authorised place(s) of business: Trading name [if different from registered name]: Licence number: Expiry date: Version number: Conditions [if any]: 21 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 6 Application for approval of person to act as company officer after licence granted Section 40, Private Security Personnel and Private Investigators Act 2010 Applicant details Company registered name: Company trading name [if different from registered name]: Company registration number: Registered office of company: Licence number: Version number: Class(es) of business: Conditions [if any]: Details of proposed officer of company First name(s): Middle name(s): Last name(s): Gender: Occupation: Date of birth: Contact details of proposed officer of company This section of the form must be completed by the proposed officer of the company.
Full residential address: Full address for communications about this application, if different from residential address: Daytime contact number: Home telephone number [optional]: Mobile number [optional]: Fax number [optional]: Email address [optional, unless applying by electronic means]: 22 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 6—continued Other name(s) This section of the form must be completed by the proposed officer of the company.
If you are known by, or have ever been known by, another name, provide details.

First name(s): Middle name(s): Last name(s): Previous licence or certificate of approval This section of the form must be completed by the proposed officer of the company.

If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.
Licence number: Certificate of approval number: Grounds of disqualification under section 62 This section of the form must be completed by the proposed officer of the company.

Note: Section 40 of the Private Security Personnel and Private Inves- tigators Act 2010 applies the grounds of disqualification listed under section 62 of the Act to proposed company officers.
I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.
I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the 23 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 6—continued offender’s interest, or for the safety of the public, or for the safety of a person or class of person).
I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an of- fence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an of- fence under section 10, 11, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.
I have/have not*, within the past 7 years, been convicted of an of- fence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an of- fence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.
I have/have not*, within the past 7 years, been convicted of an of- fence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an of- fence of violence, as defined in section 4 of the Private Security Per- sonnel and Private Investigators Act 2010.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certifi- cate of approval or employing or engaging a person without a rele- vant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.
24 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 6—continued I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Pri- vate Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.
I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval).

[You must provide proof of meeting those requirements with this applica- tion.]
I have not/have*, within the past 5 years, had 12 months’ relevant ex- perience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

[You must provide details of relevant experience with this application.]

*Select one.

Consent and certification This section of the form must be completed by the proposed officer of the company.
I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.
Date: Signature: Name: [print name] Notes 1 This application must be sent to the Private Security Personnel Licensing Authority, together with the prescribed fee, and any supporting documents, including proof of compliance with 25 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 6—continued any prescribed requirements for competency, knowledge, and skills.
The Private Security Personnel Licensing Authority must not approve this application unless the Licensing Authority is sat- isfied that— (a) the proposed officer is of or over the age of 18 years; and if any grounds of disqualification apply to the proposed officer, this does not make the company unsuitable to hold the licence.
(b) Section 105 of the Private Security Personnel and Private In- vestigators Act 2010 provides that a person who is required to provide information to the Licensing Authority and gives false information knowing that it is false or being reckless as to whether it is false is liable on summary conviction to a fine not exceeding $20,000.
2 3 26 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 7 Application for certificate of approval Section 46, Private Security Personnel and Private Investigators Act 2010 Personal details First name(s): Middle name(s): Last name(s): Gender: Occupation: Date of birth: Contact details Full residential address: Full address for communications about this application, if different from residential address: Daytime contact number: Home telephone number [optional]: Mobile number [optional]: Fax number [optional]: Email address [optional, unless applying by electronic means]: Other name(s) If you are known by, or have ever been known by, another name, provide details.
First name(s): Middle name(s): Last name(s): Previous licence or certificate of approval If you have previously held a licence or a certificate of approval under the Private Investigators and Security Guards Act 1974 or the Private Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.
Licence number: 27 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 7—continued Certificate of approval number: Class(es) of responsible employee Specify the particular class or classes of responsible employee in relation to which you are seeking a certificate of approval.
Private investigator employee Security technician employee Security consultant employee Confidential document destruction agent employee Property guard employee Personal guard employee Crowd controller employee Current employer(s) Specify the names of all your current employers, if you are employed.
Name(s) of any current employer(s): Grounds of disqualification under section 62 Note: Section 46 of the Private Security Personnel and Private In- vestigators Act 2010 applies the grounds of disqualification listed under section 62 of the Act to applicants for certificates of approval.
However, if you answer that you have met any of the grounds of dis- qualification listed below, you may provide evidence to the Licensing Authority with your application relating to your character, circum- stances, or background.

The Licensing Authority may still grant your application, but only if the Authority is satisfied that you are suitable to work in the class or classes of responsible employee to which the application relates.
Please note that no refund is payable if your ap- plication is unsuccessful.

I have/have not* been ordered by a court to be detained in a hospital owing to my mental condition and I am currently subject to such an order.
I have/have never* had an order made in relation to me under section 34(1)(b) of the Criminal Procedure (Mentally Impaired Persons) Act 2003, section 118 of the Criminal Justice Act 1985, or section 39J 28 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 7—continued of the Criminal Justice Act 1954 (being an order imposed, instead of passing sentence, that the offender be treated or cared for in a manner that the offender’s mental impairment requires, either in the offender’s interest, or for the safety of the public, or for the safety of a person or class of person).
I have/have never* been ordered by a court to be detained in a penal institution following conviction for an offence and that conviction or order has not been quashed on appeal.

I have/have never* been convicted of a specified offence as defined in section 4 of the Criminal Records (Clean Slate) Act 2004.

I have/have never* been disqualified from driving under section 65 of the Land Transport Act 1998 or an earlier equivalent provision.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an of- fence under any of sections 216H to 216J of the Crimes Act 1961.

I have/have not*, within the past 7 years, been convicted of an of- fence under section 10, 11, 13, 16, 19, 21, 24, 47F, or 47J of the Fair Trading Act 1986.
I have/have not*, within the past 7 years, been convicted of an of- fence under section 8 or 25 of the Harassment Act 1997.

I have/have not*, within the past 7 years, been convicted of an of- fence against section 6 of the Misuse of Drugs Act 1975 in relation to a Class A controlled drug, a Class B controlled drug, or a Class C controlled drug, in relation to which the amount, level, or quantity at and over which the drug is presumed to be for supply is specified in Schedule 5 of that Act.
I have/have not*, within the past 7 years, been convicted of an of- fence of dishonesty, as defined in section 4 of the Private Security Personnel and Private Investigators Act 2010 .

I have/have not*, within the past 7 years, been convicted of an of- fence of violence, as defined in section 4 of the Private Security Per- sonnel and Private Investigators Act 2010.
I have/have not*, within the past 7 years, been convicted of an of- fence under the Private Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certifi- 29 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 7—continued cate of approval or employing or engaging a person without a rele- vant certificate of approval, or an offence under section 16, 34, or 52 of the Private Investigators and Security Guards Act 1974.
I do/do not* hold a licence or certificate of approval that has been suspended.

I have/have not*, within the past 7 years, had a licence or certificate of approval cancelled under the Private Security Personnel and Pri- vate Investigators Act 2010 or the Private Investigators and Security Guards Act 1974.
I do not meet/meet* any requirements prescribed in regulations made under section 114(1)(h) of the Private Security Personnel and Private Investigators Act 2010 (which relate to the competency, knowledge, and skills required for licences and certificates of approval).

[You must provide proof of meeting those requirements with this applica- tion.]
I have not/have*, within the past 5 years, had 12 months’ relevant ex- perience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

[You must provide details of relevant experience with this application.]

*Select one.

Convictions and orders outside New Zealand Note: Section 46 of the Private Security Personnel and Private In- vestigators Act 2010 also requires that you specify these matters.
You may provide further information in support of your application (for example, evidence of your character, circumstances, or background) if you have specified a conviction or order as follows: I have/have never* been convicted outside New Zealand of an of- fence.

I have/have never* had an order imposed in relation to myself by any court or tribunal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

*Select one.
*Select one.

30 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 7—continued Applying for temporary certificate of approval If you wish to work as a responsible employee while your application for a certificate of approval is being processed, you may be eligible for a temporary certificate of approval.

This will incur an additional fee.

I wish/do not wish* to apply for a temporary certificate of approval.

*Select one.
*Select one.

Identification details Note: Only the forms of photo identification listed below are ad- equate to verify your identity.

You must provide details of one of the forms of identification.

The form of identification must not have expired more than 2 years ago.

You must bring that identification with you to be verified when you collect your certificate of approval, if your application is successful.
New Zealand driver licence* Number: Version number: Expiry date: Passport* Passport number: Date issued: Expiry date: Nationality as shown on passport: 18+ card issued by the Hospitality Association of New Zealand* Number: Firearms licence issued under section 24 of the Arms Act 1983* Number: *Select one and complete its details.
Collecting certificate of approval If your application is successful, you must collect your certificate of approval from a branch or outlet of the organisation that produces 31 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 2011/73 Form 7—continued the certificates; or if there is no such organisation, from the address specified on the Licensing Authority Internet site.

Please see the Li- censing Authority’s Internet site for details.
Complete the following if the Internet site indicates that there is an organisation producing the certificates of approval: Preferred branch/outlet: Consent and certification I consent to the Ministry of Justice undertaking a criminal history check using the information contained in my application.

I certify that the above particulars are true and correct.
Date: Signature: Name: [print name] This application must be sent to the Private Security Personnel Licensing Authority, together with the prescribed fee, and any supporting documents, including— (a) a photograph that meets the requirements prescribed in the Private Security Personnel and Private Investigators Regulations 2011; and proof of compliance with any prescribed requirements for competency, knowledge, and skills.
(b) Section 105 of the Private Security Personnel and Private In- vestigators Act 2010 provides that a person who is required to provide information to the Licensing Authority and gives false information knowing that it is false or being reckless as to whether it is false is liable on summary conviction to a fine not exceeding $20,000.
Notes 1 2 32 2011/73 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Form 8 Form of certificate of approval Section 54, Private Security Personnel and Private Investigators Act 2010 Full name: Class(es) of responsible employee: Certificate of approval number: Expiry date: Version number: Conditions [if any]: [Insert photograph] Rebecca Kitteridge, Clerk of the Executive Council.
Explanatory note This note is not part of the regulations, but is intended to indicate their general effect.

These regulations, which come into force on 1 April 2011, prescribe forms to be used under the Private Security Personnel and Private Investigators Act 2010 (the Act), which also comes into force on that date.

Issued under the authority of the Acts and Regulations Publication Act 1989.

Date of notification in Gazette: 31 March 2011.

These regulations are administered by the Ministry of Justice.
12 Wellington, New Zealand: Published under the authority of the New Zealand Government—2011 33