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Personal details

Your full name

Physical address

Are you ordinarily resident in New Zealand?

Yes

Please provide details on the amount of time spent in New Zealand and frequency, and your usual place of residence

Have you ever been convicted of an offence against any provision of the Protected Objects Act 1975 (previously known as the Antiquities Act) or of the Heritage New Zealand Pouhere Taonga Act 2014?

Yes

Conviction details

Please provide relevant details of the conviction

Where will taonga tūturu acquired under this certificate usually be held?

Contact details

Phone number (work/home)

Address

Address 2

City/Town

Postal Code