Seafarer Certificate Transition Application Form Page 7
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86. Declaration
I declare that the details provided on this form are true and correct. I confirm that any other documents
sent with this form are true and genuine, and were given and signed by the persons whose names appear
on them.
Caution
Providing false information or failing to disclose information relevant to the granting or holding of a
maritime document is an offence under section 406 of the Maritime Transport Act. The penalty for
this offence in the case of an individual is imprisonment for a term of up to 12 months or a fine of
up to NZ$10,000.
Your name
Your signature
Date
Sign here
DD / MM / YYYY
Privacy information
Personal information collected in this form will be used for the purpose of assessing your application. MNZ
will not disclose personal information other than when permitted or required by law to do so.
If you wish to access or correct personal information MNZ holds about you, please contact the MNZ
Privacy Officer at PO Box 25620, Wellington 6146, or phone (04) 473 0111.
Seafarer certificate application form
Page 7 of 8
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