X-Ray Certificate For Temporary Entry (Inz 1096)
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4OFFICE USE ONLY Client no.:
Date received:
/
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Application no.:
INZ 1096
X-ray Certificate
for Temporary Entry
Supporting information for a temporary entry visa/permit application
General information for radiologist,
About the information you
radiographer and person having the chest
provide
X-ray examination.
Immigration New Zealand collects the
This certificate must be completed by a radiologist.
information about you on this form to decide whether
Please note you may require a referral from a registered
you are eligible for a visa or permit.
medical practitioner for a chest X-ray. In most countries
Immigration New Zealand (INZ) has approved lists of panel
The address of Immigration New Zealand is
doctors and/or radiologists who will examine you. If you
PO Box 3705, Wellington, New Zealand. This is not where
require information on the panel doctors and/or radiologist
your X-ray certificate should be sent.
list, please visit your local branch or the INZ website at
Collecting the information is authorised by the
If you are not
Immigration Act 1987 and the Immigration Regulations
required to use one of the approved radiologists, any
made under that Act. You do not have to provide the
registered radiologist can complete this certificate.
information, but if you do not we are likely to decline
This certificate must be completed in English. If this
your application.
certificate or any accompanying specialist report cannot be
Immigration New Zealand may also share the
provided in English, a certified translation must be provided
information you have provided with other government
along with the original certificate or specialist report.
agencies that are entitled to it by law, or with other
The radiologist’s report must be attached to this certificate.
agencies (as you have agreed in the declaration).
Where abnormalities are present or indicated, the X-ray film
If you come to New Zealand, you will be able to ask to
must accompany this certificate.
see the information we hold about you and have any of
Any alterations to the certificate may result in the
it corrected if you think it is necessary.
certificate being returned to you and you may be required to
For more information
redo the examination. Any mistakes made must be crossed
If you have questions about completing the form:
out with one line only eg mistake.
Any false statement made on this form or non-disclosure
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see our website
may result in:
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telephone our call centre on 0508 558 855 (within
New Zealand)
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the INZ application being declined
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contact one of Immigration New Zealand’s offices.
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any visa or permit issued being revoked and the applicant
being required to leave New Zealand.
Immigration New Zealand has offices in Apia, Bangkok,
Beijing, Dubai, Ho Chi Minh City, Hong Kong, Jakarta,
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criminal prosecution punishable by up to seven years
London, Manila, Moscow, New Delhi, Nuku’alofa, Shanghai,
imprisonment.
Singapore, Suva, Sydney and Taipei.
This certificate will be retained by INZ once submitted to
Our New Zealand offices are located in Auckland,
their office.
Henderson, Manukau, Hamilton, Palmerston North,
INZ may refer this certificate to an INZ medical assessor or
Wellington, Christchurch, Queenstown and Dunedin.
New Zealand health authorities, if appropriate, as part of
assessing the associated application.
You can also contact your nearest New Zealand
Embassy or New Zealand High Commission.
If referred, the INZ medical assessor may seek a specialist
opinion. All such consultation will be treated in confidence.
For further information on immigration
July 2009
visit
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