Vetting Service

Section 2: Person being vettedto complete and return to agency

This form refers to the Policing (Police Vetting) Amendment Bill (“Vetting Bill”), which is expected to amend the Policing Act 2008 The purpose of this form is to allow the New Zealand Police Vetting Service to confirm who you are using Police records, carry out a Police vet, and obtain your consent to share any relevant information with the agency that requested the vet. What you are consenting to. You are agreeing that the Police Vetting Service can share relevant information they hold about you (if any) with the requesting agency. This information will be used to help the agency decide whether you are suitable for the role they are considering you for or that you are engaged in. The information that may be shared is outlined in section 2.4 of this form. For further details, you should refer to the Vetting Bill or visit the Police vetting website. Who collects your consent. The agency requesting the Police vet will collect your signed consent. The law that applies. Your consent is required by law. We are asking for your consent under the Vetting Bill. Your rights under the Privacy Act 2020 include: you may request a copy of the Police vet report provided to the agency by contacting the agency. You can withdraw your consent to a Police vet at any time before the vetting process is complete by contacting the agency. The agency may keep the Police vet only for as long as required for vetting purposes. You may request correction of your personal information at any time at police.govt.nz -> requesting information. How long the information is valid for. The information in the Police vet is correct only at the time it is shared. It is up to the agency to decide how often they ask for updated vetting.

1.12 Evidence of identity

A primary ID has been sighted (mandatory)A secondary ID has been sighted (mandatory)One form of ID is photographic (mandatory)Evidence of name change has been sighted (if applicable)

Primary ID - must be photographic (NZ Driver Licence or Passport)

Secondary ID - can be photographic (NZ Driver Licence or Passport) or non-photographic (bank card, student ID, government issued card)

1Family/last name

2Given/ first and middle name(s)

Date of birth (dd/mm/yyyy)

Date

Gender

Place of birth (Town/City/State)

Country of birth

NZ Driver Licence number

Name of parent or guardian (if person being vetted is 14 or 15 years old

2.2 Other names

Please include all other names you areor have been known by. Including, but not limited to: previous legal names(eg. maiden names, or due to divorce or adoption), aliases used, name changes by deed poll. Include ALL names - first, middle and last.

	Family name	First name	Middle names

2.3 Permanent residential address

Flat/ number - and street name

Suburb

Post Code

Town / City

2.4 Your consent to share information

1. A Police vet will include the following information, if held by New Zealand Police. Please refer to the Police vetting website for more information regarding the Clean Slate Scheme, what may be released, and the vetting process.

a. A result indicating that no information is held or relevant to the purpose of the vetting request,

b. The vetting subject's criminal record (if any), unless the Clean Slate Scheme applies. c. A summary of other information that is readily retrievable, relevant to the purpose of the vetting request, and deemed accurate. This may include pending charges, charges without conviction, youth court charges, infringement offences, demerit points, arrest warrants, involvement in family violence, overseas convictions, police investigations without charges, interactions with Police, and other information held by Police. Information may also be released where it is subject to a suppression order or statutory prohibition, involves offences by individuals under 18, or relates to mental health or substance abuse issues.

2. If you are vetted as a Children’s Worker, and you continue to hold that role, the Police Vetting Service may release any newly obtained relevant information to the requesting agency at any time. The Police Vetting Service will take reasonable steps to: a. confirm that the purpose of the Police vet remains valid – for example, that you are still employed or engaged as a Children’s Worker, and b. notify you before any information is disclosed.

3. Information provided in this consent form may be used to update New Zealand Police records.

Authorisation of person being vetted: I confirm that the information I have provided in this form is about me and is correct. I have read and understood the information above. I authorise New Zealand Police to disclose any personal information relevant to this application (as described above) to the agency making this request.

Full Name

Signature

Electronic signature

Date:

Date

Parent/Guardian’s full name

Parent/Guardian’s signature

If you are 14 or 15 years of age (as at the date of the application) please provide consent from a parent or guardian.

Date

Parent/Guardian’s signature

Electronic signature

* If applicable, ticking this box constitutes an electronic signature and your consent for its use in this form.

Date

Vetting Service

Either: