Personal Immigration Questionnaire

Work visa (Principal Applicant)

Please read
Please ensure that all the details you provide on this form are true and correct. The information you provide may be used in the preparation of a visa
application. It is an offence under Section 342 of the Immigration Act 2009 to provide, or cause to be provided, documents or information to Immigration
New Zealand which are false, fraudulent or misleading. Significant penalties apply. Providing incorrect information may also result in your visa application
being refused or any visa granted to you cancelled.
Please note that this is not an application form. This questionnaire is for your Immigration Adviser’s use only. Your Immigration Adviser will use the
information you provide in this questionnaire to prepare an assessment and/or your visa application(s). Remember, providing us with accurate information
will help us provide you with the best advice.

Personal details Have you ever travelled to New Zealand?

No  Yes 
Name as shown in passport
Do you hold an Australian Permanent Resident visa?
Family (last name)
Given (first, middle No  Yes 
name) Are you currently working with any other immigration adviser?

Preferred title No 
Mr Mrs
Yes  Please state the name of the adviser here

Ms Miss Dr
Other (please specify)

Partnership status
Other names you are or have been known by (eg your maiden
name) Married/in civil union  Single 
Partner*  Separated 
Engaged  Divorced 
Widowed 

* A partner includes a person you are in a relationship with (ie

Gender Male  Female  de facto, partner/boyfriend/girlfriend). INZ policy states that
partners can be of the same or opposite sex.

Day/Month/Year Will your partner or spouse be accompanying you to New

Zealand?
Date of birth
No  Yes 
Place of birth If you answered yes, please answer the next two questions
Town/city below:

Province 1. Have you been convicted in the last 7 years of any offence
involving domestic violence or of a sexual nature in any
Country country, or are you currently under investigation for such an
offence?
Details from your passport
Passport number No 
Country of Citizenship Yes  Please provide details

Are you a citizen of any other country?

No  2. Do you consent to Immigration New Zealand providing
Yes  Please list all countries of citizenship information about you to your partner/intended, if deemed
necessary for the assessment of their application?

No  Yes 

National Identity number

Contact details
Your current residential address
Have you previously applied for any type of New Zealand visa or
have a current New Zealand visa application in process (eg
visitor, work, residence etc)?
No 
Yes  Please provide us with a copy of the visa label

Have you previously requested an NZeTA (New Zealand

Electronic Travel Authority)?
No  Yes 

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Street
address Name
Address
Suburb or
District
Phone (landline) ( ) ( )
Town or city
Phone (mobile) ( ) ( )
Region Email
DD/MM/YY

Post code Dave of birth Relationship

(if known)
Travel dates
Your current telephone numbers
Day/Month/Year
Country Area Number
What date do you intend to
Phone (landline) ( ) ( ) enter New Zealand?
Phone (mobile) If you are currently in New
Email Zealand, what was the date
which you first arrived in New
Name and address for communication about this application (if Zealand? (Whether as a
different from above). visitor or holding a work visa.)
This information should be on
Your passport and original documents will be returned to you
at this address (or the one noted above) unless indicated your entry stamp in your
otherwise. passport.

Name
Address
Health requirements
Do you have tuberculosis (TB)?
No 
Country Area Number Yes  Give details
Phone (landline) ( ) ( )
Phone (mobile) ( ) ( )
Email
Do you have any medical condition that currently requires, or
Are you currently in New Zealand? may require, one of the following during your intended stay in
New Zealand?
No 
Residential care is defined as in-patient care for people with a
Yes  Please provide your most recent address physical, sensory, intellectual or psychiatric disability or lived-
outside New Zealand in facilities for the aged.
Renal dialysis No  Yes  If yes to any of these
Hospitalisation No  Yes  questions, please provide
details below
Residential care No  Yes 

Please list the name, address, contact details and relationship of

any friends, relatives or contacts you have in New Zealand
Name
Address
Are you pregnant?
No 
Phone (landline) ( ) ( )
Yes  Date you are due to give birth:
Phone (mobile) ( ) ( )
Please note that if you intend to give birth in New Zealand, you
Email
may have to provide evidence that you have at least NZ$9,000
DD/MM/YY of funds available if you are not eligible for publicly funded
Dave of birth Relationship maternity services.
(if known)
Have you submitted any medical certificates to INZ in the last
36 months?
Name
Address

Phone (landline) ( ) ( )
Phone (mobile) ( ) ( )
Email
DD/MM/YY

Dave of birth Relationship

(if known)

191141_2
No  Have you ever been expelled, deported, excluded, removed from
or refused entry to any country?
Yes  Give details below
Type of visa application
Date application was lodged with INZ
Date medical certificate was issued by
doctor

Please note here any and all medical conditions you have or
have had in the past that may or will require medical care or
monitoring in the future.

Have you spent a combined total of three months or more in

any country in the past 5-year period, other than your country
of citizenship?
No 
Yes  Please state the applicable country/countries

Character details
Please list all countries you have lived in for 5 years or more
since the age of 17.

Have you submitted any Police Certificates to INZ with any

previous application?
No 
Yes  If yes, please provide the following:
Date police certificate was issued
Date prior application was lodged

Have you ever been convicted at any time of any offence,

including any driving offence? (You must include all
convictions).

No 
Yes  Please provide details below

Are you currently under investigation, wanted for questioning,

or facing charges for any offence in any country including New
Zealand?
No 
Yes  Please provide details below

191141_2
No 
Yes  Please provide details below

Have you ever been refused a visa or permit by any country,

including New Zealand?
No 
Yes  Please provide details below

Are you currently wanted for questioning for any offence(s)

against the law in any country, including New Zealand?
No 
Yes  Please provide details below

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?
No 
Yes  Please provide details below

Have you ever been a member of, or adhered to, any terrorist
organisation?

No 

Yes  Please provide details below

Employment
If you are currently employed, provide details
Employer’s name
Employer’s address
- Street address
- Town or city
- Region
- Post code

Country Area Number

Employer’s phone ( ) ( )
Employers email
Your position
Your start date
191141_2
Give details of all periods of employment starting with your current job or most recent, including self-employment.

Period* Location (province/region and Type of

Name of employer
MM YY country) work/occupation/job title
From
To
Please provide a detailed description
of your duties for this role

Period* Location (province/region and Type of

Name of employer
MM YY country) work/occupation/job title
From
To
Please provide a detailed description
of your duties for this role

Period* Location (province/region and Type of

Name of employer
MM YY country) work/occupation/job title
From
To
Please provide a detailed description
of your duties for this role

Period* Location (province/region and Type of

Name of employer
MM YY country) work/occupation/job title
From
To
Please provide a detailed description
of your duties for this role

Period* Location (province/region and Type of

Name of employer
MM YY country) work/occupation/job title
From
To
Please provide a detailed description
of your duties for this role

* If you do not know the exact date, please provide an approximate date.
Give details of all qualifications you currently hold (excluding secondary school)

Date commenced and

completed study* Name of qualification Institution where qualification gained
DD MM YY
From
To

Date commenced and Institution where qualification gained

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 completed study*
Name of qualification
DD MM YY
From
To
From
To
From
To

* If you do not know the exact date, please provide an approximate date.

Additional information
Please include details below:
Section Additional information

PwC 6