AUCKLAND

LEVEL 7                                                           PHONE: 921 8800
186-194 QUAY STREET                                  FAX: 921 8822
PRICE WATERHOUSE-COOPERS TOWER
AUCKLAND
NEW ZEALAND

CONSENT TO DISCLOSURE OF INFORMATION

 I………………………………………………………………………………………….
(SURNAME)                                (FORENAMES)

…………………………………………………………………………………………..
(MAIDEN OR ANY OTHER NAMES USED)

SEX:……(M/F) DATE AND PLACE OF BIRTH:………………………………

NATIONALITY:…………………… ADDRESS:……………………………...

…………………………………………………………………………………………..

I confirm that I am aware that my full criminal record will be released even if I meet the eligibility criteria stipulated in section 7 of the Criminal Records (Clean Slate) Act 2004 due to the application of section 14(3)(b)(ii) of that Act.

Hereby consent to the disclosure by the New Zealand Police of any information they may have pursuant to this application to the AUSTRALIAN AUTHORITIES FOR VISA PURPOSES ONLY.

SIGNED:……………………………….    DATE: ………………………………….

COMMENTS OF NEW ZEALAND POLICE