Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1698835684974.pdf (New Zealand)
Reprint as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 (SR 2011/73) Private Security Personnel and Private Investigators (Forms) Regulations 2011: revoked, on 1 May 2019, by section 340(1) of the Tribunals Powers and Procedures Legislation Act 2018 (2018 No 51).
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 Page 2 2 2 2 1 2 3 4 Note Changes authorised by subpart 2 of Part 2 of the Legislation Act 2012 have been made in this official reprint.

Note 4 at the end of this reprint provides a list of the amendments incorporated.

These regulations are administered by the Ministry of Justice.
1 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 Applying for company licence Notice of intention to apply for licence Notice of intention to apply for licence 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 2 3 3 3 3 3 3 4 Title These regulations are the Private Security Personnel and Private 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 Pri- vate 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 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 r 11 Notice of intention to apply for licence 6 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 publica- tion on its Internet site in form 3 of the Schedule.
Issuing licences 7 8 9 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 10 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 11 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 Reprinted as at 1 May 2019 Schedule Forms rr 4–11 Form 1 Application by individual for licence Section 24, 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 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 Security Personnel and Private Investigators Act 2010, provide your licence number or certificate number.
Licence number: Certificate of approval number: 4 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule 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 application 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 Repossession agent Grounds of disqualification under section 62 Note: Section 62 of the Private Security Personnel and Private Investigators Act 2010 lists certain grounds that may disqualify you from being granted a licence or certifi- cate 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, circumstances, or background.

The Licensing Authority may still grant your application, but only if the Authority is satis- fied that you are suitable to carry on the class or classes of business to which the application relates.

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 Crim- inal 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 inter- est, 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 fol- lowing conviction for an offence and that conviction or order has not been quashed on appeal.

5 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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 offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence 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 offence under section 10, 11, 12A, 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 offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.
I have/have 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.
I have/have 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 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, 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 offence under the Pri- vate Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a per- son without a relevant 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 can- celled under the Private Security Personnel and Private 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.]

6 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule I have not/have*, within the past 5 years, had 12 months’ relevant experience as a licensee or responsible employee in the class or classes of private security business to which the application relates.
Note: This ground applies only to applications for licences for a class of private security business other than that of repossession agent.

You must provide details of relevant experience with this application.
I am applying for a licence as a repossession agent and I have/have not*, within the past 5 years, had 12 months’ relevant experience— (a) (b) of carrying on a business of repossessing consumer goods (either by myself or in partnership with any other person) on behalf of a creditor; or of repossessing consumer goods in the course of my employment, or engage- ment as a contractor, by a person who carries on a business referred to in para- graph (a) or by a creditor.
[You must provide details of relevant experience with this application.]

*Select one.

Convictions and orders outside New Zealand Note: Section 24 of the Private Security Personnel and Private Investigators 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 offence.

I have/have never* had an order imposed in relation to myself by any court or tribu- nal 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 details: Name(s) of any current employer(s): 7 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 Identification details Note: Only the forms of photo identification listed below are adequate 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 iden- tification 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: 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: 8 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule 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— (a) (b) 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.
2 Section 105 of the Private Security Personnel and Private Investigators 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 conviction to a fine not exceeding $20,000.

Schedule form 1: amended, on 6 March 2015, by regulation 4(1) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 1: amended, on 6 March 2015, by regulation 4(2) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 1: amended, on 6 March 2015, by regulation 4(3) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 1: amended, on 6 March 2015, by regulation 4(4) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 1: amended, on 6 March 2015, by regulation 4(5) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 1: amended, on 17 June 2014, by section 41(2) of the Fair Trading Amendment Act 2013 (2013 No 143).
Schedule form 1: amended, on 1 July 2013, by section 413 of the Criminal Procedure Act 2011 (2011 No 81).
9 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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 Investigators 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 regard- ing this application.
Name: Daytime contact number: Home telephone number [optional]: Mobile number [optional]: Fax number [optional]: Email address [optional, unless applying by electronic means]: 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 10 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Property guard Personal guard Crowd controller Repossession agent 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 Investigators 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 application 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 application 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, 12A, 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 under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

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.
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 Investigators 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.
11 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 The company has/has not*, within the past 7 years, had a licence cancelled under the Private Security Personnel and Private Investigators Act 2010 or the Private Investi- gators and Security Guards Act 1974.
The company has/does not have* any officer of the company who was, or is, an offi- cer of another company (whether or not that other company is still in existence) that, within the past 7 years, had a licence cancelled under the Private Security Personnel and Private Investigators 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 Investigators 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 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 application relates.

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

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 Secur- ity 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]: 12 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule 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.

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 Investigators 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.
How- ever, 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 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 applica- tion 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 Crim- inal 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 inter- est, 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 fol- lowing conviction for an offence and that conviction or order has not been quashed on appeal.

13 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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 offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence 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 offence under section 10, 11, 12A, 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 offence under section 8 or 25 of the Harassment Act 1997.
I have/have 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.
I have/have 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 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, 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 offence under the Pri- vate Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a per- son without a relevant 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 can- celled under the Private Security Personnel and Private 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.]
14 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule I have not/have*, within the past 5 years, had 12 months’ relevant experience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

Note: This ground applies only to applications for licences for a class of private security business other than that of repossession agent.
You must provide details of relevant experience with this application.
The company is applying for a licence as a repossession agent and I have/have not*, within the past 5 years, had 12 months’ relevant experience— (a) (b) of carrying on a business of repossessing consumer goods (either by myself or in partnership with any other person) on behalf of a creditor; or of repossessing consumer goods in the course of my employment, or engage- ment as a contractor, by a person who carries on a business referred to in para- graph (a) or by a creditor.
[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 Investigators 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 offence.

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

*Select one.
*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] 15 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 Schedule Notes 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 compe- tency, knowledge, and skills.
Section 105 of the Private Security Personnel and Private Investigators 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 conviction to a fine not exceeding $20,000.

Schedule form 2: amended, on 6 March 2015, by regulation 6(1) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 2: amended, on 6 March 2015, by regulation 6(2) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 2: amended, on 6 March 2015, by regulation 6(3) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 2: amended, on 6 March 2015, by regulation 6(4) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 2: amended, on 6 March 2015, by regulation 6(5) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 2: amended, on 17 June 2014, by section 41(2) of the Fair Trading Amendment Act 2013 (2013 No 143).
Schedule form 2: amended, on 1 July 2013, by section 413 of the Criminal Procedure Act 2011 (2011 No 81).
1 2 16 Reprinted as at 1 May 2019 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 licence to operate [class(es) of busi- ness].
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 following: 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.
17 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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] 18 Reprinted as at 1 May 2019 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]: 19 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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]: 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): 20 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule 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 Investigators 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 Crim- inal 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 inter- est, 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 fol- lowing 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 offence under the Arms Act 1983.

I have/have not*, within the past 7 years, been convicted of an offence 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 offence under section 10, 11, 12A, 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 offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

21 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.
I have/have 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.
I have/have 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 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, 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 offence under the Pri- vate Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a per- son without a relevant 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 can- celled under the Private Security Personnel and Private 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 experience as a licensee or responsible employee in the class or classes of private security business to which the application relates.

Note: This ground applies only if the company has a licence for a class of private security business other than that of repossession agent.

You must provide details of relevant experience with this application.
The company has a licence as a repossession agent and I have/have not*, within the past 5 years, had 12 months’ relevant experience— of carrying on a business of repossessing consumer goods (either by myself or in partnership with any other person) on behalf of a creditor; or of repossessing consumer goods in the course of my employment, or engage- ment as a contractor, by a person who carries on a business referred to in para- graph (a) or by a creditor.
[You must provide details of relevant experience with this application.]

(a) (b) 22 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule *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 2 3 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 compe- tency, knowledge, and skills.
The Private Security Personnel Licensing Authority must not approve this application unless the Licensing Authority is satisfied that— (a) (b) 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.
Section 105 of the Private Security Personnel and Private Investigators 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 conviction to a fine not exceeding $20,000.

Schedule form 6: amended, on 6 March 2015, by regulation 8(1) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 6: amended, on 6 March 2015, by regulation 8(2) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 6: amended, on 6 March 2015, by regulation 8(3) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 6: amended, on 6 March 2015, by regulation 8(4) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 6: amended, on 17 June 2014, by section 41(2) of the Fair Trading Amendment Act 2013 (2013 No 143).

Schedule form 6: amended, on 1 July 2013, by section 413 of the Criminal Procedure Act 2011 (2011 No 81).
23 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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: 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 24 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule Security technician employee Security consultant employee Confidential document destruction agent employee Property guard employee Personal guard employee Crowd controller employee Repossession 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 Investigators 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 disqualification listed below, you may provide evidence to the Licensing Authority with your application relating to your character, circumstances, or back- ground.

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 respon- sible employee to which the application relates.
Please note that no refund is payable if your 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 Crim- inal 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 inter- est, 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 fol- lowing 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 offence under the Arms Act 1983.

25 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 I have/have not*, within the past 7 years, been convicted of an offence 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 offence under section 10, 11, 12A, 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 offence under section 103(1) of the Credit Contracts and Consumer Finance Act 2003 that involves a breach of any provision of Part 3A of that Act.

I have/have not*, within the past 7 years, been convicted of an offence under section 8 or 25 of the Harassment Act 1997.
I have/have 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.
I have/have 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 .

I have/have not*, within the past 7 years, been convicted of an offence of violence, 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 offence under the Pri- vate Security Personnel and Private Investigators Act 2010 of working while not holding a licence or relevant certificate of approval or employing or engaging a per- son without a relevant 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 can- celled under the Private Security Personnel and Private 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.]

*Select one.

Convictions and orders outside New Zealand Note: Section 46 of the Private Security Personnel and Private Investigators 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: 26 Reprinted as at 1 May 2019 Private Security Personnel and Private Investigators (Forms) Regulations 2011 Schedule I have/have never* been convicted outside New Zealand of an offence.
I have/have never* had an order imposed in relation to myself by any court or tribu- nal outside New Zealand, instead of passing sentence, that I be treated or cared for in relation to a mental impairment.

*Select one.

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.

Identification details Note: Only the forms of photo identification listed below are adequate 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 iden- tification 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 the certificates; 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 27 Schedule Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 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] 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) (b) 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.
2 Section 105 of the Private Security Personnel and Private Investigators 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 conviction to a fine not exceeding $20,000.

Schedule form 7: amended, on 6 March 2015, by regulation 10(1) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).
Schedule form 7: amended, on 6 March 2015, by regulation 10(2) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 7: amended, on 6 March 2015, by regulation 10(3) of the Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24).

Schedule form 7: amended, on 17 June 2014, by section 41(2) of the Fair Trading Amendment Act 2013 (2013 No 143).
Schedule form 7: amended, on 1 July 2013, by section 413 of the Criminal Procedure Act 2011 (2011 No 81).
28 Reprinted as at 1 May 2019 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] Issued under the authority of the Legislation Act 2012.

Date of notification in Gazette: 31 March 2011.


Rebecca Kitteridge, Clerk of the Executive Council.

29 Notes Private Security Personnel and Private Investigators (Forms) Regulations 2011 Reprinted as at 1 May 2019 Reprints notes 1 General This is a reprint of the Private Security Personnel and Private Investigators (Forms) Regulations 2011 that incorporates all the amendments to those regula- tions as at the date of the last amendment to them.
2 Legal status Reprints are presumed to correctly state, as at the date of the reprint, the law enacted by the principal enactment and by any amendments to that enactment.

Section 18 of the Legislation Act 2012 provides that this reprint, published in electronic form, has the status of an official version under section 17 of that Act.

A printed version of the reprint produced directly from this official elec- tronic version also has official status.
3 Editorial and format changes Editorial and format changes to reprints are made using the powers under sec- tions 24 to 26 of the Legislation Act 2012.

See also http://www.pco.parlia- ment.govt.nz/editorial-conventions/.
4 Amendments incorporated in this reprint Tribunals Powers and Procedures Legislation Act 2018 (2018 No 51): section 340(1) Private Security Personnel and Private Investigators (Forms) Amendment Regulations 2015 (LI 2015/24) Fair Trading Amendment Act 2013 (2013 No 143): section 41(2) Criminal Procedure Act 2011 (2011 No 81): section 413 Wellington, New Zealand: Published under the authority of the New Zealand Government—2019 30