OFFICE USE ONLY Client no.

Date received:

Application no.:

INZ 1139

Supplementary Form for Fiji Citizens

Complete this form if you are a citizen of Fiji
As part of the processing of your application for a visa, you are required to complete the following form. Making a false or misleading statement in respect of entry to New Zealand can result in the refusal of your application. If a visa has been granted, you may become liable for deportation and required to leave New Zealand. When filling in this form, please print clearly in English using CAPITAL LETTERS.

Section A

Personal details
Given/first name(s)

A1 Name as shown in passport Family/last name

A2 Other names you are known by or have ever been known by

A3 Date of birth

A4 At any time since 6 December 2006 (including currently) have you, your partner, or either of your parents been a member of the Republic of Fiji Military Force (RFMF) (including being a territorial)? Yes
Provide details

No

A5 Are you, your partner or either of your parents currently a close associate of Josaia Voreqe (Frank) Bainimarama? OR Have any of you been his close associate since 6 December 2006? Yes
Provide details

No

A6 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
Provide details

No

For further information on immigration visit www.immigration.govt.nz

April 2011

When filling in this form, please print clearly using CAPITAL LETTERS.

A7 Are you, your partner, or either of your parents currently directly or indirectly associated with the activities of Josaia Voreqe (Frank) Bainimarama and his associates? OR Have any of you been directly or indirectly associated with him or his associates since 6 December 2006? Yes
Provide details

Section B

Applicants declaration

No

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, I may become liable for deportation, 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.

A8 Are you, your partner or either of your parents currently a permanent secretary in a Fiji government department? Yes
Provide details

Signature
Note that a parent or guardian may sign on behalf of any children aged under 18 years.

No

Date

A9 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
Provide details

About the information you provide

Deciding whether you are eligible for a visa
Immigration New Zealand collects the information about you on this form to decide whether you are eligible for a visa. We may also use the information to contact you for research purposes or to advise you on immigration matters. The address of Immigration New Zealand is PO Box 3705, Wellington, New Zealand. This is not where your application should be sent. Collecting the information is authorised by the Immigration Act 2009 and the Immigration Regulations made under that Act. You do not have to provide the information, but if you do not we are likely to decline your application.

No

A10 Do you intend to be in New Zealand for the purpose of playing sport? Yes
Provide details

No

A11 Do you intend to transit through New Zealand for the purpose of playing sport in another country? Yes
Provide details

No

Deciding whether you are eligible to board a flight to New Zealand

The information we collect may also be used to determine whether you are allowed to board a flight to New Zealand. We will not share your personal information with airline check-in agents; however, we will send a boarding message to the airline check-in agent based on the information you have provided in this form. Immigration New Zealand may also share the information you have provided with other government agencies that are entitled to it by law, or with other agencies (as you have agreed in the declaration). If you come to New Zealand, you will be able to ask to see the information we hold about you and have any of it corrected if you think it is necessary.

2 Supplementary Form for Fiji Citizens

This form has been approved under section 381 of the Immigration Act 2009