OFFICE USE ONLY Client no.: Date received: / / Registration no.

July 2021 INZ 1092

Pacific Access Category

Registration Form
This form is available free of charge from Immigration New Zealand.

Use the applicable guide to help you complete the registration form
The registration guides contain important information on how to complete the registration form. It also contains
information about the registration process and the requirements for residence under the Pacific Access Category
if your registration is successfully drawn from the ballot. The following guides are available:
• Pacific Access Category (Fiji) Registration Guide (INZ 1230)
• Pacific Access Category (Kiribati) Registration Guide (INZ 1231)
• Pacific Access Category (Tonga) Registration Guide (INZ 1233)
• Pacific Access Category (Tuvalu) Registration Guide (INZ 1229)

These can be downloaded from www.immigration.govt.nz/forms or collected from an Immigration New Zealand office.

Documents required
Use the checklist below to find out which documents you must provide. If you have not provided the required
documents, Immigration New Zealand cannot accept your registration into the ballot.

OFFICE Please make sure your Pacific Access Category Registration Form includes all the following requirements.
USE
ONLY
If you do not meet any of the following requirements your registration will not be accepted.
Completed and signed registration form.
Photocopies of birth certificates for the principal registrant, any partner and dependent children included
in this registration form.
Note: For speed of registration processing and document security, please provide photocopies instead of original birth certificates.
I have included the correct registration fee.
Note: Refer to ‘Step 3’ in the applicable registration guide for the correct fee amount in the local currency.

I have included the correct visa application centre fee (if applicable).

Send your registration to the correct address

Ensure you have the correct receiving office details. Refer to ‘Step 4’ in your country’s guide or visit
www.immigration.govt.nz/fees.

Immigration Advisers Licensing Act 2007

Under the Immigration Advisers Licensing Act 2007 it is an offence to provide immigration advice without being
licensed or exempt. If your immigration adviser is not licensed when they should be, Immigration New Zealand will
return your application.
For more information and to view the register of licensed advisers, go to the Immigration Advisers Authority website
www.iaa.govt.nz or email [email protected].
Lawyers provide immigration advice and are exempt from licensing under the Immigration Advisers Licensing Act 2007.
For more information and to view the register of immigration lawyers, go to the New Zealand Law Society website
www.lawsociety.org.nz.

immigration.govt.nz
 When filling in this form, please write clearly using CAPITAL LETTERS.

Which Pacific Access Category are you applying for?

Fiji Kiribati Tonga Tuvalu

Section A Principal registrant’s details

A1 Name as shown in passport (or birth certificate if you do not have a passport)
Family/last name

Given/first name(s)

A2 Preferred title Mr Mrs Ms Miss Dr Other (specify)

A3 Other names you are known by or have ever been known by (include the full name on your original birth certificate
if different from A1 ).

A4 Gender Male Female A5 Date of birth Attach a photocopy of

D D M M Y Y Y Y your birth certificate.

A6 Country of birth

A7 Country/countries of citizenship

A8 Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

Section B Contact details

B1 Your current residential address

Telephone (mobile)* (Please include the international calling code)

 
Telephone (landline)  
Email*

*Please provide a mobile telephone number and/or email address so that we can contact you about this registration.

B2 Name and address for communication if we need to contact you about this registration (please include
a PO Box address if you are able)
Same as address at B1 , or Other Provide details

Name

Address

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 Telephone (mobile)* (Please include the international calling code)
 
Telephone (landline)
 
Email*

*Please provide a mobile telephone number and/or email address so we can contact you about this registration.

B3 Do you authorise the person stated at B2 to act on your behalf? Yes No

B4 Have you received immigration advice on this registration?

You can find a definition of immigration advice at www.immigration.govt.nz/advice.

Yes Please make sure that your immigration adviser completes Section E: Immigration adviser’s details.
No

Section C Principal registrant’s family details

Provide details of all your immediate family members (partner and dependent children) who will be included in your
application for residence under the Pacific Access Category if your registration is selected from the ballot and you are
invited to apply for residence. List names as shown in passport (if they have one) or birth certificate (if they do not
have a passport). If no family members are included, please state ‘None’ in C1 and C2.
For definition of partner and dependent children, see ‘Completing Section C: Principal registrant’s family details’
in the Pacific Access Category registration guide that is applicable to you.
Note: Any existing partner or dependent children that you do not declare in this registration form cannot be
included in your application for residence under the Pacific Access Category. If they apply for residence in the
future under the Partnership Category or Dependent Child Category, their application also cannot be approved.
However, any child that you have (either born or adopted) after the registration was submitted may be included
in your application for residence. If you have a new partner after your registration was submitted, they may also
be included in your application for residence if the partnership requirements are met.

C1 Partner (attach a photocopy of your partner’s birth certificate)
Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

C2 Dependent child 1 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

Pacific Access Category Registration – July 2021 – 3

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

C3 Dependent child 2 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

C4 Dependent child 3 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

C5 Dependent child 4 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

C6 Dependent child 5 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

C7 Dependent child 6 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

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 C8 Dependent child 7 (attach a photocopy of your child’s birth certificate)
Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

C9 Dependent child 8 (attach a photocopy of your child’s birth certificate)

Family name First/given names

Country of citizenship Country of residence

Gender Male Female Date of birth D D M M Y Y Y Y

Partnership status Married/in civil union Never married/never in civil union Partner/De facto
Separated Engaged Widowed Divorced

If you have any other dependent children, please continue on a separate sheet of paper.

Section D Declaration by principal registrant

Note: INZ cannot accept your registration if it is not signed by the principal registrant.
Do you give permission for Immigration New Zealand to announce your name over the radio if we are unable to
contact you by mail, email, or other means?
Yes No
I understand that if I have received immigration advice from an immigration adviser who is not licensed under the
Immigration Advisers Licensing Act 2007 when they should be, Immigration New Zealand will return my registration.
I understand the notes and questions in this form and the information I have given is true and complete.

Signature of principal registrant Date D D M M Y Y Y Y

Section E Immigration adviser’s details

This section must be completed by the principal registrant’s immigration adviser. If the registrant does not
have an immigration adviser, this section does not have to be completed.

E1 If you are a licensed adviser, please provide your licence details.

Licence type full provisional limited List conditions specified in the register.

Licence number 2 0 Go to Section F: Declaration by person assisting the registrant to complete this form.

Pacific Access Category Registration – July 2021 – 5

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

E2 If you are exempt from licensing, tick one box below to show why you are exempt from licensing then
go to Section F: Declaration by person assisting the registrant to complete this form.
I provided immigration advice in an informal or family context only, and I did not provide the advice
systematically or for a fee.
I have provided immigration advice in the course of my work (employed or volunteer) and that work exempts
me from the requirement to be licensed. Indicate the reason for your exemption below.
Lawyer with current New Zealand practicing certificate Community Law Centre Citizens Advice Bureau
New Zealand Member of Parliament or staff New Zealand public servant Foreign Diplomatic/Consular
See www.immigration.govt.nz/advice for more information about who is exempt from licensing.

Section F Declaration by person assisting the principal registrant to complete this form
This section must be completed and signed by the registrant’s immigration adviser, or by any person who has
assisted the registrant by providing immigration advice, explaining, translating, or recording information on the
form for the registrant. If the registrant does not have an immigration adviser, and no one helped the registrant
to fill in this form, this section does not have to be completed.
If you are not exempt under the Immigration Advisers Licensing Act 2007, it is an offence for you to provide immigration advice without holding
a license, and Immigration New Zealand will refuse to accept your client’s registration. More information about immigration adviser licensing
can be obtained from the Immigration Advisers Authority website www.iaa.govt.nz, via email [email protected] or by telephone on 0508 422 422.

Name and address of person assisting registrant. Same as address given at B2 , or as below.
Family/last name Given/first name(s)

Company name (if applicable) and address

New Zealand Business Number (if applicable) For help search: www.nzbn.govt.nz

Telephone Email

I understand that after the registrant has signed this form it is an offence for me to change or add further
information, change any documents attached to the form, or attach any further documents to the form. However,
if changes are needed, the person making the changes must state on the form what information or documents have
been changed and give reasons for the changes.
I note that the maximum penalty for this offence is a fine of up to NZ$100,000 and/or a term of imprisonment
of up to seven years.
I certify that the registrant asked me to help them complete this form and any additional forms. I certify that the
registrant agreed that the information provided was correct before signing the declaration.
I have assisted the registrant as an interpreter/translator
I have assisted the registrant with recording information on the form
I have assisted the registrant in another way. Specify
I have provided immigration advice (as defined in the Immigration Advisers Licensing Act 2007) and my details
in Section E: Immigration adviser’s details are correct.

Signature of person assisting Date D D M M Y Y Y Y

6 – Pacific Access Category Registration – July 2021

 Section G Paying your registration fee
About the information you provide
To find out how much to pay, payment methods and where
Deciding whether you are eligible to register to send your application, see immigration.govt.nz/fees
under the Pacific Access Category
Your registration fee
Immigration New Zealand collects the information
about you on this form to decide whether you Amount you are paying:
are eligible to register under the Pacific Access
Category. We may also use the information to Currency
contact you for research purposes or to advise
you on immigration matters. Registration number
(office use only)
Collecting the information is authorised by
the Immigration Act 2009 and the Immigration
Credit/debit card details
Regulations made under that Act.
Immigration New Zealand may also share Mastercard Visa
the information you have provided with other
Name of cardholder
government agencies that are entitled to it
by law, or with other agencies.
You are able to ask for the information we hold Card number
about you and have any of it corrected if you
think it is necessary. The address of Immigration
New Zealand is PO Box 1473, Wellington 6140, CVC/CVV number
New Zealand. Do not send your registration
to this address. Note: Your CVC/CVV number is the three-digit number found on the
signature strip on the back of your credit/debit card.

Expiry date D D M M Y Y Y Y

Signature of cardholder

Date D D M M Y Y Y Y

Pacific Access Category Registration – July 2021 – 7

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

8 – Pacific Access Category Registration – July 2021