NZIS 1139

For INZ use

Supplementary form for Application number

citizens of Fiji
Client number

Date received / /

Please complete this form if you are a citizen of Fiji.

As part of the processing of your application for an your application or if a visa has been issued and/or a permit
immigration visa or permit, you are required to complete the granted, the cancellation of your visa or revocation of your
following form. Making a false or misleading statement in permit. If your permit is revoked after entry to New Zealand
respect of entry to New Zealand can result in the refusal of you will be required to leave New Zealand.

Section A: PERSONAL DETAILS

A1 Your family name A5

Are you, or have you been at any time since 6 December
2006, a close associate of any other person involved in
carrying out the 2006 Fiji coup? Yes No
Your given name
If ‘Yes’, please provide details

Any other names you are, or have been known by

DD M M Y Y
A2 Date of birth (day/month/year eg. 18/10/75)

Place of birth A6
Were you, or are you currently, directly or indirectly associated
with the activities of Josaia Voreqe (Frank) Bainimarama and his
A3 At any time since 6 December 2006 (including currently) have
associates? Yes No
you, your partner, or either of your parents been a member of
the Republic of Fiji Military Force (RFMF) (including being a
If ‘Yes’, please provide details
territorial)? Yes No

If ‘Yes’, please provide details

A7
Are you, your partner or either of your parents currently a
permanent secretary in a Fiji government department?
A4
Are you, or have you been at any time since 6 December 2006, Yes No
a close associate of Josaia Voreqe (Frank) Bainimarama?
Yes No If ‘Yes’, please provide details
If ‘Yes’, please provide details

A8 Have you, your partner or either of your parents
been appointed by the interim Fiji government to any board(s)
of statutory authorities and/or public enterprises?
Yes No
If ‘Yes’, please provide details
A9 Do you intend to be in New Zealand for the purpose of
playing sport? Yes No
If ‘Yes’, please provide details
Section B: PRIVACY ACT
• The information about you on this form is collected to
determine your eligibility for an immigration visa or permit
and may also be used to contact you for research purposes
or to advise you on immigration matters. This information
may also be used to determine your entitlement to board a
flight to come to or return to New Zealand.
• Your personal information will not be shared with airline
check-in agents; however a boarding message will be
returned to the airline check-in agent based on information
you have supplied on this form.
• The main recipient of the information is Immigration
New Zealand, a service of the Department of Labour but
it may also be shared with other Government agencies
which are entitled to this information under applicable
legislation, or with other agencies in accordance with an
authority in the form.
pg 2 Supplementary Form for Citizens of Fiji (NZIS 1139)
A10 Do you intend to transit through New Zealand for
the purpose of playing sport in another country?
Yes No
If ‘Yes’, please provide details
A11 I understand the questions and content of this form,
and the information I have given is true and correct. I
understand that if I make a false or misleading statement,
my application may be declined or, if it has been approved,
my visa or permit may be revoked, and that I may also be
committing an offence and be liable for prosecution.
I understand that if I make a false or misleading statement
it may impact on my ability to enter or transit through New
Zealand in the future.
Signature of applicant
Note: a parent or guardian may sign on behalf of any
children aged under 17 years.
DD M M Y Y Date (day/month/year eg. 27/11/04)
• Our address is PO Box 3705, Wellington, New Zealand, but
please send your application to the nearest appropriate
Immigration New Zealand branch office or New Zealand
Embassy or High Commission.
• The collection of the information is authorised by the
Immigration Act 1987 and the Immigration Regulations
made under that Act. The supply of the information is
voluntary, but if you do not supply it then your application
is likely to be declined.
• You will, if you come to New Zealand, have a right to see
the information about you held by INZ and to ask for any of
it to be corrected if you think that is necessary.
This form has been approved under s132(1) of the Immigration Act 1987
August 2007