Pilot Licence (Pl) Application Form - Maritime New Zealand Page 3
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4SECTION 6
To be completed only for the issue of a
replacement Maritime Document
Grade(s) / Area(s)
Certificate Number(s)
Date(s) of Issue
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Declaration:
I,
(Full Name)
of
(Address)
do solemnly and sincerely declare that:
my certificate(s)/licence(s), particulars of which are given above, was/were lost/destroyed (circle correct option)
at
(Place)
on
(Date)
under the following circumstances: (give full details – continue on separate sheet of paper if necessary)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
The statements made herein, and in sections 1, 2 and 3 of this form, are correct and true to the best of my knowledge
and belief.
And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and
Declarations Act 1957.
(CAUTION – Every person who makes a false representation for the purpose of obtaining a Maritime
Document is liable to imprisonment for a period not exceeding 12 months or to a fine not exceeding $5,000).
Signature:
______________________________________________________________________________________
Declared at:_________________________________ on _________________________________________________
Before me:
_____________________________________________________________________________________
______________________________________________________________________________________________
(a person authorised to take a statutory declaration within the meaning of the Oaths and Declarations Act 1957, e.g.
Justice of the Peace, Barrister or Solicitor of the High Court of New Zealand – the person must sign and state his/her
full name and qualification for taking the declaration)
Please proceed to Section 7 to ensure your application is complete and all relevant documentation is enclosed
Version 4 – July 2017
Page 3 of 4
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