Client Intake Form - Principal Applicant

Please complete all questions on the form.

You will only see questions that are relevant to you depending on the answers you gave in previous questions.

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Your details

Personal details - Principal Applicant
Name (as in passport)*
Title First Last
Other names you have been known by, eg. maiden name or preferred name
Name Type
Gender*
Date of birth*
DD dash MM dash YYYY
Place of birth*
Country of birth*
Passport details*
Passport number Issue date Expiry date Country of issue
Other citizenships you have
Birth Certificate Details
Birth certificate number Issuing Authority Country of issue
Contact details - principal applicant
Address*
Street Address City ZIP / Postal Code Country
Email*
Enter Email Confirm Email
(Mobile) Phone*
Relationship details
Are you in a relationship?*
You are in a genuine relationship if you are dating and/or living together with a partner/spouse with the intention that the relationship will last. A De Facto relationship is a where you and your partner are living together as a couple on a genuine domestic basis and are not married or in a civil union.
- Yes
- Yes, but my partner is an New Zealand or Australian citizen or (permanent) resident
- No
Your spouse/partner's name (as in their passport)*
Title First Last
What is your relationship status?*
Are you?*
Is your partner/spouse coming with you to New Zealand (or already with you in NZ)?*
- Yes
- No
When did your relationship start?*
DD dash MM dash YYYY
Are you living together?*
- Yes
- No
When did you start living together?*
DD dash MM dash YYYY
Do you and your partner have any children together (biological or adopted)?*
- Yes
- No
Any comments you'd like to make about your relationship?
New Zealand visa details - principal applicant
Do you currently hold a valid visa for New Zealand?*
- Yes
- No
What type of visa do you have?*
Do You know the visa sub-type?*
Expiry date visa?*
DD dash MM dash YYYY
Please provide details of New Zealand visa(s) you held in the past
Type of visa (e.g. work visa) Visa subtype (e.g. Essential Skills) Start date (dd/mm/yyyy) End date (dd/mm/yyyy)
INZ client number?*

You can find the client number on your visa label
Your most recent overseas address*
Street Address City ZIP / Postal Code Country
Is a visa application for New Zealand ever declined?*
- Yes
- No
Please provide details of why the visa was declined , when and what type of visa*
Have you completed an English language test?*
e.g. IELTS or Pearson PTE
- Yes
- No
When did you take the English test?*
DD dash MM dash YYYY
What where your test scores*
Listening Reading Writing Speaking Overall
Did you complete a medical check and/or chest X-ray with a previous application?*
Date medical check*
DD dash MM dash YYYY
Date chest X-ray*
DD dash MM dash YYYY
Did you provide a police clearance certificate with a previous visa application?*
- Yes
- No
Please list the countries that you submitted a Police Clearance Certificate (PCC) for*
PCC Country PCC Date of issue

Use the + to add more rows
Health details - principal applicant
Do you or are you likely to require dialysis treatment?*
- Yes
- No
Do you have tuberculosis?*
- Yes
- No
Do you have severe haemophilia?*
- Yes
- No
Do you have a physical incapacity that requires full-time care?*
- Yes
- No
Have you been exposed to or diagnosed with any infectious or communicable disease?*
- Yes
- No
Are you receiving, or have received, any treatment for any psychiatric condition or developmental disorder?*
- Yes
- No
Have you had any (serious) medical conditions in the past or have you been operated on?*
- Yes
- No
Do you have any condition that is likely to require ongoing treatment or medication?*
- Yes
- No
Do you have any other medical conditions that do not fall in the above categories?*
- Yes
- No
If you answered Yes to any of the question above, please explain*
Are you pregnant?
- Yes
- No
When is your due date?*
DD dash MM dash YYYY
Please list all countries where you lived for 3 months or more since you were 17 (including your home country)*
Country Arrival date Departure date

You can add rows by clicking the +
Character details - principal applicant
Are you currently: under investigation, wanted for questioning or facing charges?*
- Yes
- No
Have you ever been convicted of an offence (including a traffic/driving offence)? Note that this includes any conviction(s) in any country outside New Zealand cleared or wiped by ‘clean slate’ legislation.*
- Yes
- No
Have you ever been charged with, convicted of or investigated for any offences committed (including traffic or driving offences) since being granted New Zealand residence, or while on a temporary visa or when unlawfully in New Zealand?*
- Yes
- No
Have you ever been sentenced to serve a period of time in prison or other form of detention (including any suspended sentences or any expunged criminal records)?*
- Yes
- No
Have you ever been placed on probation?*
- Yes
- No
Have you ever been asked to leave a country voluntarily or have you been deported from a country , including New Zealand?*
- Yes
- No
Have you ever been refused entry (=barred) to any country, including New Zealand?*
- Yes
- No
Have you ever been refused (=declined )a visa/permit to visit, work, study or reside in any country, including New Zealand?*
- Yes
- No
Have you ever had any other visa issues?*
e.g. overstaying or breaching your visa conditions
- Yes
- No
Have you ever been involved in any terrorist activities or advocated similar violent activities?*
- Yes
- No
Have you ever been a member of, or adhered to, any terrorist organisation?*
- Yes
- No
Have you been involved in any drug trading or trafficking?*
- Yes
- No
Have you ever been a member of, or associated with, any organisation or group with criminal objectives or which has engaged in criminal activities or advocated such activities?*
- Yes
- No
Have you ever been a member of, or associated with, any group of persons or organisation which, at the time of membership or association, had objectives which were based on hostility against persons or groups of persons on the basis of their colour, race, or ethnic or national origin, or were based on a representation that persons of a particular race or colour are inherently inferior or superior to other races or colours?*
- Yes
- No
Have you at any time in a public speech or public comments, or public broadcast, or in publicly distributing or publishing a document, argued that one race or colour is inherently inferior or superior to another race or colour; or used language intended to encourage hostility or ill will against any person or group of persons on the basis of colour, race, or ethnic or national origins of that person or group?*
- Yes
- No
Have you had (or currently have) an association with, membership of, or involvement with, any government, regime, group or agency that has advocated or committed war crimes, crimes against humanity and/or other gross human rights abuses?*
- Yes
- No
If you have answered yes to any of the above questions, please explain*
Employment & Qualifications - principal applicant
Please list all periods of relevant employment, including your current employment*
Start date (mm/yyyy) End date (mm/yyyy) Name Employer Address employer Position title

Use the + to add more employment history
Please list your tertiary qualifications
Name of the qualification Major Education provider (name and country) Date diploma/degree awarded

Use the + to add more qualifications
Family details
Please list your children from previous relationships
List biological, step and adopted children. Use to + to add more rows Do NOT list children you have with your current spouse/partner. You can list them further along in the questionnaire.
Full name Date of birth Gender Nationality Included in application?
Please list your family members*
Provide details of: (1) your parents and (2) your siblings. Include biological and stepfamily. Use the + to add more rows.
Full name Date of birth Gender Country of residence Relationship status Occupation
Dependent child 1
Name as in passport - child 1*
First Last
Gender - child 1*
Date of birth - child 1*
DD dash MM dash YYYY
Place of birth - child 1*
Country of birth - child 1*
Passport details - child 1*
Passport number Issue date Expiry date Country of issue
Other citizenships the child has - child 1
Birth certificate details - child 1
Birth certificate number Issuing authority Country of issue
Is this child included in the application? - child 1*
- Yes
- No
Please provide information if this child has or had a (serious) medical condition that requires specialist visits, operations, medication or special schooling arrangements? - child 1
Please provide information if this child has Character issues (convictions - even a traffic offense - or visa issues) - child 1
Do you have more children with your partner/spouse?*
- Yes
- No
Dependent child 2
Name as in passport - child 2*
First Last
Gender - child 2*
Date of birth - child 2*
DD dash MM dash YYYY
Place of birth - child 2*
Country of birth - child 2*
Passport details - child 2*
Passport number Issue date Expiry date Country of issue
Other citizenships the child has - child 2
Birth certificate details - child 2
Birth certificate number Issuing authority Country of issue
Is this child included in the application? - child 2*
- Yes
- No
Please provide information if this child has or had a (serious) medical condition that requires specialist visits, operations, medication or special schooling arrangements? - child 2
Please provide information if this child has Character issues (convictions - even a traffic offense - or visa issues) - child 2
Do you have a third child with your partner/spouse?*
- Yes
- No
Dependent child 3
Name as in passport - child 3*
First Last
Gender - child 3*
Date of birth - child 3*
DD dash MM dash YYYY
Place of birth - child 3*
Country of birth - child 3*
Passport details - child 3*
Passport number Issue date Expiry date Country of issue
Other citizenships the child has - child 3
Birth certificate details - child 3
Birth certificate number Issuing authority Country of issue
Is this child included in the application? - child 3*
- Yes
- No
Please provide information if this child has or had a (serious) medical condition that requires specialist visits, operations, medication or special schooling arrangements? - child 3
Please provide information if this child has Character issues (convictions - even a traffic offense - or visa issues) - child 3
Do you have another child with your partner/spouse?*
- Yes
- No
Dependent child 4
Name as in passport - child 4*
First Last
Gender - child 4*
Date of birth - child 4*
DD dash MM dash YYYY
Place of birth - child 4*
Country of birth - child 4*
Passport details - child 4*
Passport number Issue date Expiry date Country of issue
Other citizenships the child has - child 4
Birth certificate details - child 4
Birth certificate number Issuing authority Country of issue
Is this child included in the application? - child 4*
- Yes
- No
Please provide information if this child has or had a (serious) medical condition that requires specialist visits, operations, medication or special schooling arrangements? - child 4
Please provide information if this child has Character issues (convictions - even a traffic offense - or visa issues) - child 4
Name
First Last

Save and Continue Later

Type of visa (e.g. work visa)	Visa subtype (e.g. Essential Skills)	Start date (dd/mm/yyyy)	End date (dd/mm/yyyy)

Start date (mm/yyyy)	End date (mm/yyyy)	Name Employer	Address employer	Position title

Name of the qualification	Major	Education provider (name and country)	Date diploma/degree awarded

Full name	Date of birth	Gender	Nationality	Included in application?

PCC Country	PCC Date of issue

Country	Arrival date	Departure date

Full name	Date of birth	Gender	Country of residence	Relationship status	Occupation

Client Intake Form - Principal Applicant

Your details

Personal details - Principal Applicant

Contact details - principal applicant

Relationship details

New Zealand visa details - principal applicant

Health details - principal applicant

Character details - principal applicant

Employment & Qualifications - principal applicant

Family details

Dependent child 1

Dependent child 2

Dependent child 3

Dependent child 4