PERSONAL DETAILS
*
Full Name (s):
*
Date of Birth
*
Age
Mobile Number
Work Number
Email Address
NZ Driver's License number
Version number (5b)
Passport
Country of issue
When do you intend to move in?
How long do you intend to stay?
(Please note there is a minimum stay of 4 weeks)
Present residential address
How long were you at this address?
Why are you leaving this address?
If you have health issues and wish to register your health practitioner please so otherwise leave blank
If so, please discuss with us in confidence. You may be asked to complete our Secondary Registration Form.
Do you have any criminal convictions?
Yes
No
If so, please discuss with us in confidence. You may be asked to complete our Secondary Registration Form.
Case Worker/Social Worker
Phone Number
EMPLOYMENT HISTORY
What is your source of income?
Name of current employer?
How long have you worked for this employer?
Do you receive a benefit?
Yes
No
What is your Winz number?
If you receive a benefit how long have you been without work?
MOTOR VEHICLE DETAILS
Will you be parking a vehicle on the property?
Yes
No
Make and Model of car?
Registration number
NEXT OF KIN
Name
Relationship to you
Address
Mobile Number
Home Number
Date
Signature