New Zealand Connect Declaration Form

New Zealand Connect Declaration Form
Full Name (as per NRIC / Pass)*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Passport Number*
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Marital Status*
Apart from Auckland, which other city in New Zealand will you prefer to work in?

WellingtonChristchurchDunedinRotoruaQueenstownTaurangaHamiltonNapierNew PlymouthNelsonPalmerston NorthInvercargillGisborneLower HuttHastingsNorth ShorePoriruaAny - I have no preferenceOther
Character Declarations
Have you ever been convicted of any offences and sentenced to a prison term of 5 years or longer?*

YesNo
Have you been convicted of any offences in the last 10 years and sentenced to a term in prison of 12 months or longer?*

YesNo
Have you ever been prohibited from entering New Zealand or any other country?*

YesNo
Have you ever been removed, excluded, or deported from any country?*

YesNo
Have you been convicted at any time for an offence for which you have been imprisoned?*

YesNo
If yes, please provide information on the circumstances (what happened) and significance (severity) of the offence: *
Have you been convicted at any time for an offence for which you could have been sentenced to 3 months or longer in prison?*

YesNo
If yes, please provide information on the circumstances (what happened) and significance (severity) of the offence: *
Have you been convicted at any time for an offence for which you have been charged or are under investigation for serious criminal offending?*

YesNo
If yes, please provide information on the circumstances (what happened) and significance (severity) of the offence: *
Have you been convicted at any time for an offence for which you have provided New Zealand with misleading information about your own, or anyone else’s visa or residence application?*

YesNo
If yes, please provide information on the circumstances (what happened) and significance (severity) of the offence: *
Health Declaration
Have you ever contracted tuberculosis (TB / MDR-TB / XDR-TB)?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you ever used intravenous drugs?*

YesNo
Have you ever had a blood transfusion?*

YesNo
Have you been diagnosed with Hepatitis B-surface antigen positive OR Hepatitis C-RNA positive?*

YesNo
Have you had a past history of cancer?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you previously undergone an organ transplant? (If corneal graft, you may select "No")*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of severe, chronic or progressive renal or hepatic disorders?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of musculoskeletal diseases or disorders such as osteoarthritis?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of severe, chronic or progressive neurological disorders including but not limited to: any dementia including Alzheimer's disease, poorly controlled epilepsy, complex seizure disorder, cerebrovascular disease, cerebral palsy, paraplegia, quadriplegia, poliomyelitis, Parkinson’s disease, motor neurone disease, Huntington’s disease, muscular dystrophy, prion disease, relapsing and/or progressive multiple sclerosis?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of cardiac disease including but not limited to: severe ischaemic heart disease, cardiomyopathy, valve disease with a high probability of surgical and/or other procedural intervention in the next five years, aortic aneurysm with a high probability of surgical and/or other procedural intervention in the next five years?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of chronic respiratory disease including but not limited to: severe and/or progressive restrictive (including interstitial) lung disease, severe and/or progressive obstructive lung disease, or cystic fibrosis?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of significant or disabling hereditary disorders, including but not exclusive to: hereditary anaemias and coagulation disorders, primary immuno-deficiencies, or Gaucher’s disease?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you had a past history of severe autoimmune disease, currently being treated with immune-suppressant medications other than Prednisone, Methotrexate, Azathioprine or Salazopyrin?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Have you been diagnosed with major psychiatric illness and/or addiction including any psychiatric condition that has required hospitalisation and/or where significant support is required?*

YesNo
If yes, please provide information regarding your condition and your current treatment costs:*
Do any of these conditions apply?*

Severe (71-90 decibels) hearing loss or profound bilateral sensori-neural hearing loss after best possible correction at country of origin, where significant support is required, including cochlear implantsSevere vision impairment with visual acuity of 6/36 or beyond after best possible correction at country of origin, or a loss restricting the field of vision to 15-20 degrees where significant support is requiredSevere developmental disorders or severe cognitive impairments where significant support is required, including but not exclusive to: physical disability, intellectual disability, autistic spectrum disorders, brain injuryNone of the above
If you have any children: do any of your children have any physical, intellectual, or sensory conditions or difficulty with their use of language and social communication abilities that may impact their education needs? i.e. special education needs, etc.*

YesNoNot Applicable
If yes, please provide information regarding the child, their condition, and their needs:*
Immigration Declarations
Have you ever stayed in New Zealand after your visa has expired?*

YesNo
Have you ever breached any New Zealand visa conditions?*

YesNo
Do you have any family members who is in New Zealand without a visa?*

YesNo
If yes, please provide further informaton:*
Have you previously had any visa applications declined by any country?*

YesNo
If yes, please provide further informaton:*
Declaration of Work Experience
In which role do you work / specialise in?*
If OTHERS, please state:*
How many years of relevant work experience do you have?*
What is your CURRENT job title?*
What is your preferred occupation in New Zealand?*
Are you willing to work in roles that may be below your current level of experience if it can help you move to New Zealand sooner?*

YesNo
Are you currently employed or have previously been employed under any of the following occupations?

AnaesthetistAnalyst ProgrammerDairy Cattle Farmer (Dairy Cattle Farm Manager) including Dairy Farm Manager, Assistant Dairy Farm Manager and Dairy Herd ManagerConstruction Project ManagerProject Builder (including Building Project Manager and Site Foreman)Chief Information OfficerICT Project ManagerICT Managers necSurveyorOther spatial scientistChemical EngineerMaterials EngineerCivil EngineerGeotechnical EngineerQuantity SurveyorStructural EngineerElectrical EngineerElectronics EngineerIndustrial EngineerMechanical EngineerProduction or Plant EngineerEnvironmental EngineerAcoustic EngineerCalibration EngineerCorrosion EngineerEngineering Professionals necFire Safety EngineerMechatronics EngineerProduct Design EngineerSafety EngineerTest and Activation Engineer (Naval Shipbuilding)Food TechnologistEnvironmental Research ScientistMedical Laboratory ScientistVeterinarianPhysicist (medical)Early Childhood (pre-primary school) Teacher – registeredSecondary School TeacherMedical diagnostic (Medical Imaging Technologist)Medical Radiation TherapistSonographerOrthoptistOccupational TherapistPodiatristAudiologistGeneral PractitionerResident Medical OfficerAnaesthetistSpecialist Physician (General Medicine)CardiologistClinical HaematologistMedical OncologistEndocrinologistGastroenterologistIntensive Care SpecialistNeurologistPaediatricianRenal Medicine SpecialistRheumatologistThoracic Medicine SpecialistSpecialist Physician necPsychiatristSurgeon (General)Cardiothoracic SurgeonNeurosurgeonOrthopaedic SurgeonOtorhinolaryngologistPaediatric SurgeonPlastic and Reconstructive SurgeonUrologistVascular SurgeonDermatologistEmergency Medicine SpecialistObstetrician and GynaecologistOphthalmologistPathologistDiagnostic and Interventional RadiologistRadiation OncologistMedical Practitioners necMidwifeRegistered Nurse (aged care)Registered Nurse (child and family health)Registered Nurse (community health)Registered Nurse (critical care and emergency)Registered Nurse (developmental disability)Registered Nurse (disability and rehabilitation)Registered Nurse (medical)Registered Nurse (medical practice)Registered Nurse (mental health)Registered Nurse (perioperative)Registered Nurse (surgical)Registered Nurse (paediatrics)Registered Nurses necMultimedia SpecialistAnalyst ProgrammerDeveloper ProgrammerSoftware EngineerSoftware TesterSoftware and Applications Programmers necICT Security SpecialistTelecommunications EngineerTelecommunications Network EngineerClinical PsychologistEducational PsychologistOrganisational PsychologistPsychotherapistPsychologists necAnaesthetic TechnicianMedical Laboratory TechnicianCivil Engineering TechnicianElectrical Engineering TechnicianElectronic Engineering TechnicianAutomotive ElectricianDiesel Motor Mechanic (including Heavy Vehicle Inspector)Plumber (general)Electrician (general)None of the Above
Do you have any of the following licences?

Class 1 (drivers with physical disabilities)Class 2/2A/2B (motorcycle riders)Class 3/3A/3C/3CA (car owners)Class 4A (bus drivers)Class 4/5 (heavy motor drivers i.e. trucks and vans)None of the AboveOther
Declaration of Educational Qualifications
What is your highest educational qualification?*
From which school did you graduate?*
In which country did you obtain this qualification?
In which year was this qualification obtained?
Confirmation of Information

I hereby confirm that all information provided in this form is true and correct to the best of my knowledge. I understand that withholding, omitting, or providing false information in this form may lead to serious consequences related to my ability to legally work and/or reside in New Zealand and I bear full responsibility for any negative consequences arising from withheld / omitted / false information provided in this form, including but not limited to all governmental application results and/or applications for visas, residency, and occupational registration.
Signature*

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New Zealand Connect Declaration Form

Character Declarations

Health Declaration

Immigration Declarations

Declaration of Work Experience

Declaration of Educational Qualifications

Confirmation of Information