1. society
2. work
3. unions

URUNGA WHAIMANA
TE AHO TĀTAIRANGI
1. Kōrero whaiaro
4. Tātai tohu
Ingoa whānau: Te ingoa o te/ngā kura tuarua i kuraina ai koe:
Ingoa ake:
Rā
Marama
Tau
Rā whānau:
TOHU KURA TUARUA
Me whakarārangi ngā kaupapa ako i ākona ai e koe me ngā taumata/
māka/kaute i riro mai mō ngā tohu nei. Me tāpiri hoki he kape o ngā hua
kua waitohua.
Tau Tuakiri:
(ina mōhiotia)
2. Tō reo
Ko te reo Ingarihi, reo Māori rānei tō reo tuatahi?
Āe
Kāo
Mēnā ‘Kāo’ he aha kē tō reo tuatahi?
Kaupapa ako
Mēnā ‘kāo’, kāore hoki he tohu Whakauru Whare Wānanga āu nō
tētahi whenua reo Ingarihi, he tohu rānei i whakaakona ai ki te reo
Ingarihi me tāpiri he kape o ngā hua o te whakamātautau IELTS (te mea
pūmātauranga). Me neke atu i te 7.0 te tapeke i ngā taumata katoa o te
whakamātautau IELTS.
HĀUNGA IA
Ko te kaiako kua rēhita ki Te Pouherenga Kaiako o Aotearoa, he Tohu
Kaiako hoki tāna ka wātea mai i tēnei paearu reo Ingarihi.
Mēnā kua ako koe ki tētahi kura tuarua ki Aotearoa nei mō te rua tau
neke atu, ā, e waru ngā whiwhinga o te Kaupae 2 o NCEA Whakauru
Whare Wānanga (e whā mō te pānui, e whā hoki mō te tuhituhi) ka
wātea mai i ngā paearu mō te aromatawai IELTS.
He kōrero atu anō kei te pae ipurangi nei: www.teacherscouncil.govt.nz.
3. Hauora
MĀTAURANGA ATU ANŌ
He mate nōu (ā-tinana, ā-hinengaro) e tautāwhi ai i tō āhei ki te mahi
whakaako i runga i te haumaru me te tika? Āe
Kāo
He mate hauora nōu kia hiahia āwhina i a koe e ako ana?
NCEA Kaupae 1 / NCEA Kaupae 2 / NCEA Kaupae 3 /
Kura Tiwhikete Tiwhikete Tau 12
Takuhe
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Kua riro mai
E mahia ana
Āe
Kāo
Mēnā ‘Āe’ tō whakautu ki t/ētahi o ēnei kōrero, tēnā koa,
whakamāramahia mai:
Mēnā, mai i te puta i te kura, e ako ana koe i āianei i tētahi kuratini,
whare wānanga, tētahi atu wāhi rānei, tēnā koa:
zztuhia ngā kōrero i raro iho nei, me te
tāpiri i tētahi kape o ngā tohu me ngā māka kua riro mai.
Ingoa o te wānanga/ Tohu i whiwhi
whakahaere
mai/ako mai koe
Kia maumahara: I ētahi wā mā te ākonga tonu he taraiwa atu ki te kura
hāpai/pokapū me te hoki mai. He haora pea te roa i ētahi wā mai i tō
kāinga ki ētahi kura
Te/Ngā kaupapa
ako matua
Kua tutuki
Āe
Kāo
Āe
Kāo
Āe
Kāo
5. Pūrongo Mātakitaki
Hei āwhina i a mātou kia kitea tō pai mō te mahi kaiwhakaako, me ōu
nā pūkenga tuhituhi, me mātakitaki koe i tētahi rōpū tamariki e ako
ana kātahi ka tukua mai he PŪRONGO MĀTAKITAKI. Me tiki te puka
PŪRONGO MĀTAKITAKI hei mahi māu.
6. Kōrero tautoko
Mā te tuhi ā-ringa ki tētahi atu pepa, tuhia mai, ki te reo Ingarihi (reo
Māori rānei), te take i whirihia ai e koe tēnei kaupapa hei whāinga māu.
Tuhia mai ōu ake āhuatanga papai hei tautoko i tō tono.
TE AHO TĀTAIRANGI
7. Huarahi Umanga/wheako
Mēnā kua whai mahi koe ahakoa te roa, me tuhi ngā kōrero. Kia mōhio: Pai tonu ngā mahi utu kore.
Rangatira
Tūnga
Momo mahi
Rā i riro mai
8. Mahi o mua
Me tuhituhi he kōrero poto e pā ana ki tētahi mahi ki ngā tamariki/taiohi, tētahi kōrero rānei mō ēnei e whai ake nei:
Mahi tahi me ngā tamariki/taiohi
Mahi Toi
Ngā mahi ā-hapori
Ētahi atu ahurea
Ngā mahi ā-kura
Haerenga
Hākinakina
Mahi whakaako/Hākinakina
Pūoro
Ako ā-waho
Whakaari
Ētahi atu
Tuhia ki tētahi atu pepa ina hiahia ana.
URUNGA WHAIMANA: TE AHO TĀTAIRANGI
9. Kaiwawao
13.Tukanga whiriwhiri
Hei āwhina i a mātou kia whakaarohia tō tono, me homai kia rua ngā
kōrero tautoko. Tēnā koa, tuhia ki raro nei te ingoa me te īmēra a ia
tangata i hoatu ai he puka Pūrongo Kaiwawao.
Ka uiuia katoatia ngā ākonga tika hei wāhanga o te tukanga whiriwhiri.
Ka tū ngā uiuitanga ki Manawatū me ētahi atu tāone huri noa, mā Skype
rānei. Ka whakamōhiotia atu te rā, te haora me te wāhi o tō uiuitanga, ā,
ka wātea mai te whānau, ētahi hoa rānei hei tautoko ina hiahiatia. Tēnā
pea ka inoi atu kia oti i a koe t/ētahi o ngā aromatawai e whai ake nei:
Ingoa o te kaitautoko tuatahi:
1. He tauira nō te NCEA 3 Te Reo Rangatira – aromatawai ā-waho mō te
pānui, tuhituhi rānei;
Īmēra a te kaitautoko tuatahi:
2. He aromatawai reo Māori i takea mai i ngā whakamātautau Taumata
1 o Te Kunenga ki Pūrehuroa kia kitea tō āhei rānei ki te ako i te
Taumata 5;
Ingoa o te kaitautoko tuarua:
3. He aromatawai pāngarau o ngā aromatawai o te NCEA Pāngarau
Kaupae 1.
Īmēra a te kaitautoko tuarua:
Ka whakamōhiotia atu mēnā ka hiahiatia kia mahia e koe tētahi o ēnei
aromatawai i te wā ka mōhio koe mō āhea uiuia ai koe.
10.Pūrongo Kura/Kura tuatoru
14.Kupu pono
Me hoatu ki tō kura te puka PŪRONGO KURA/KURA TUATORU. He
wāhanga tēnei o tō tono.
E mea ana au he tika, he pono ngā kōrero katoa kua tuhia mai nei:
Waitohu:
11.Te Kura Hāpai
Ki te hiahia te tangata ki te whai i tēnei kaupapa me tautoko atu tētahi
Kura Kaupapa Māori i a koe. Me tuku mai i te taha o tō tono te puka TE
KURA HĀPAI kua oti i tō Kura te whakakī.
Te rā:
12.Kupu whakaae
COMPLETING YOUR ENROLMENT APPLICATION
Mea mai ai te Kura Mātauranga kia āta tirohia e te Pūtahi Licensing &
Vetting Service ngā ākonga kua whirihia mō tēnei kaupapa. Me oti i a koe
te Puka Kupu Whakaae te whakakī, ā, me whakautu hoki i ēnei pātai.
After completing this form, go to enrol.massey.ac.nz to complete your
enrolment application online.
Kua whiua koe e taea ai te kī mai i raro i te Criminal Records (Clean Slate)
Act 2004?
Āe
Kāo
He whiunga e ora tonu ana?
Āe
Kāo
Kua noho koe i tētahi atu whenua, atu i a Aotearoa, mō te kotahi tau
neke atu i roto i te tekau tau ka hori ake?
Āe
Kāo
Mēnā ‘Āe’, me homai tētahi kape o tētahi puka arowhai pirihimana
mai i ia whenua. Kaua rā e tuku mai i te mea tūturu, waiho tērā mō Te
Pouherenga Kaiako o Aotearoa ā tōna wā. Me tuhi i raro nei:
Mai i
Whenua
Marama
Ki
Tau
Marama
Arowhai pirihimana:
Kua tāpirihia
Kua tonoa
Arowhai pirihimana:
Kua tāpirihia
Kua tonoa
Arowhai pirihimana:
Kua tāpirihia
Kua tonoa
Tau
Rā
Marama
Tau
TE KURA HĀPAI
Me tono koe ki tētehi o ngā Kura Kaupapa Māori e noho ana i raro i
te maru o Te Rūnanga nui o ngā Kura Kaupapa Māori o Aotearoa ki te
noho hei Kura Hāpai mōu. Ko tā te Kura Hāpai he awhi, he tautoko, he
akiaki i a koe i roto i tō hīkoi ki te whakatutuki i ngā akoranga mā reira
ka whakatohua koe me te Tohu o Te Aho Tātairangi.
Mehemea kāore tō Kura Hāpai, ka taea e Te Rūnanga nui o ngā Kura
Kaupapa Māori a koe te āwhina. Me whakapā atu koe ki Toni Waho:
[email protected] rānei, ki 021 483 161 rānei.
Te ingoa o te Kura Hāpai:
Ko Te Kura Kaupapa Māori o: E whakaae ana tēnei kura ki te noho hei Kura Hāpai hei tautoko i a
(te ingoa o te kaitono):
E whakaae ana tēnei kura ki te hāpai i te kaitono nei mā te:
{{ whakawātea i tētehi wāhi o te kura hei wāhi mahi mō te kaitono
{{ whakawātea i tētehi rorohiko a te kura hei whakamahinga mā te
kaitono
{{ tuku i te kaitono ki roto i ngā akomanga o te kura hei
mātakitakitanga māna, hei whēako whakaako māna
{{ tautoko i te kaitono i te wā ka hiahia tautoko a ia ki te whakatutuki
i ana taumahi
{{ tauawhiawhi i te kaitono kia rongo a ia i te wairua tautoko, hāpai
{{ hui ki te tauira kia rite tonu te wā ki te rongo e pēhea ana te haere
o te tauira ki te whai i te tohu o Te Aho Tātairangi
Te Waitohu a
Te Tumuaki o Te Kura Kaupapa Māori o
Rā
Marama
Tau
Te rā:
15
PŪRONGO MĀTAKI – TE AHO TĀTAIRANGI
Kia āwhina mai i a mātou ki te aromatawai i tō pai ki te tū hei kaiako me mātakitaki koe i tētahi rōpū ākonga o te taumata e hāngai ana ki tō te hōtaka e
tonoa ana e koe. Me haere atu koe ki tētahi kura, tētahi kōhanga reo rānei mō te haurua rangi, mō tētahi akoranga rānei (mēnā he kura tuarua). Me oti
katoa ngā wāhanga te tuhi ki tētahi rerenga kōrero roa, ā, me mahi tētahi atu pepa hei whakaoti. Ka āwhina tēnei pūrongo i a mātou ki te aromatawai
i ōu pūkenga tuhituhi nō reira me nui atu i te 400 ngā kupu. Me pātai atu ki te Tumuaki, Pouako, Kaitiaki, tō Kaiarataki rānei o taua rangi ki te whakaoti i
te wāhanga “Whakamana Toronga” i raro iho nei o tēnei pūrongo.
Me tāpiri atu tēnei pūrongo ki tō tono mō Te Kunenga ki Pūrehuroa ka whakahoki atu ai ki:
Enrolments, Te Kunenga ki Pūrehuroa, Private Bag 11222, Papaioea 4442.
Pūrongo mātaki
Ingoa o te kaitono
Hōtaka e tonoa ana
Tau tuakiri o te kaitono
Tuhia he rerenga kōrero roa hei whakaahua i te/ngā akomanga i mātakihia e koe me ngā mahi i mahia ai i te wā i reira koe.
Meatia tētahi atu pepa ina kī tonu tēnei
Me āta whakaahua (rerenga kōrero roa)
• he aha ngā momo pūkenga/rautaki i kitea ai
• ngā mahi a ngā tamariki e tohu ana i pēhea rā ngā tamariki i ako ai
Meatia tētahi atu pepa ina kī tonu tēnei
Whakamana Toronga
Mea ana au i toro mai a (te ingoa o te kaimātaki)
ki (te ingoa o te kura, kōhanga reo rānei)
i te (te rā)
Waitohu
PŪRONGO TAPU O TE KURA – TE AHO TĀTAIRANGI
Kia oti anake mō ngā ākonga e tono ana mai i te kura, i tētahi whare whakangungu tūmataiti rānei. Tēnā koa, me whakahoki mai tēnei pūrongo ki:
Enrolments, Te Kunenga ki Pūrehuroa, Private Bag 11222, Papaioea 4442.
Pūrongo ā-kura
Autaia ana
Eke Taumata
Waenganui
Ako tonu ana
He kōrero anō
Eke Taumata
Waenganui
Ako tonu ana
Pūkenga Whakawhiti Whakaaro
(Me whakataurite te kaitono ki ētahi
atu o ngā ākonga tuākana me te tohu
mai i ngā pouaka e tika ana)
Kura/Whare Whakangungu
Autaia ana
Ingoa
He kōrero anō
Pānui
Reo ā-tuhi
Reo ā-waha (kounga o te reo,
mārama, matatau)
Ētahi atu kōrero (hei tauira: e taea ana
tētahi atu reo te kōrero, manu kōrero)
Pūkenga Whaiaro
(Me whakataurite te kaitono i ētahi
atu ākonga tuākana me te tohu mai i
ngā pouaka e tika ana)
Kua pakeke
Pūkenga whakahoahoa
Whakahāngai
Ihuoneone
Hinengaro koi
Pūkenga arataki
Whakawhirinaki
Ngākau pono
Whakawhiti whakaaro
Whakawhiti kōrero
Pūkenga ahurea, ā-hapori
Tuhia he kōrero mō ōna wheako ki ngā papori o Aotearoa me ētahi atu, tae atu ki ngā kākano rua, ahurea matatini, kiritini, ā-tuawhenua, ā-tāone,
mahi, mahi i ngā hararei, mahi ki tāwāhi me tōna koi ki ngā mahi ā-hapū, ā-iwi.
PŪRONGO TAPU O TE KURA – TE AHO TĀTAIRANGI
Me tuhi he kōrero mō āna mahi i te kura, i te hapori
Me tuhi ngā kaupapa ako e ākona i āianei, te taumata o te ako me te taumata pea ka ekea i tēnei tau (meatia UB mō te Tohu Takuhe, NCEA
mō NCEA)
Kaupapa ako
Taumata
Māka pea ka riro mai
He kōrero anō
Kua riro mai rānei i te kaitono ngā paearu pāngarau, reo matatini mō te Tohu Whakauru Whare Wānanga?
Āe
Kāo
E ako ana kia riro mai?
Ka riro mai i tēnei tau te Tohu Whakauru Whare Wānanga o te Taumata 3 NCEA?
Āe mārika
Tōna tikanga
Kāore pea
Karekau pea
Aua hoki
Akoako Whare Wānanga: Ka eke taumata te kaitono i te whare wānanga?
Āe mārika
Tōna tikanga
Kāore pea
Karekau pea
Aua hoki
Ihiihi/ū ki te kaupapa
Tū māia/kakama
Whai ngākau ki te tangata
Kua pakeke
Ako tonu ana
Waenganui
Eke Taumata
Tangata hei kāiako
(Me tohu ki tāu e mōhio ai.
Waiho ki te kore e mōhio)
Autaia ana
He kōrero anō (hei tauira ngā paearu pāngarau, reo matatini)
Māka (Tohua)
Hei kaiako:
Āe mārika
1
2
3
4
5
Kāre pai
5
Kāre pai
Tōna āhei ki te whakatutuki i tēnei tohu kaiako:
Āe mārika
1
2
3
4
Kua hoatu tēnei pūrongo i runga anō i te mōhio he mea tapu
tēnei pūrongo ki ngā tāngata o te paewhiri.
Waitohu o te Tumuaki
Mahi tahi
Oranga tinana/Hinengaro
Tōna āhua
He kōrero anō
Rā
Tēnā rawa atu koe mōu i whai wā ki te whakakī i tēnei
pūrongo. Ka mihia koe e Te Kunenga ki Pūrehuroa mō ōu nā
kōrero.
REFEREE’S REPORT
The purpose of this Reference is to support students applying for
selected entry programmes of study at Massey University.
Applicant’s details (to be completed by the applicant)
This form will remain confidential to members of the selection team.
Surname:
Thank you for acting as a referee for the applicant named to the right.
Your assistance will help us assess the applicant’s suitability for their
proposed programme of study at Massey University. It would be greatly
appreciated if you could fill out this Reference and return it within 14
days of receiving it from the applicant via either:
Forename:
zzEmail to [email protected] (as a scanned PDF of
the completed and signed document), or:
zzPost to:
Academic Services, Massey University
Private Bag 11222, Palmerston North 4442
Day
Month
Year
Date of birth:
Student ID:
(if known)
Email:
Please complete this Reference if you have known the applicant for one
year or more in the capacity of employer, educator, work colleague or
person of community standing, ie Kaumatua, Minister or similar. Please
do not complete this form if you are a flatmate, friend or relative of the
applicant, or if you are unable to provide the requested information due
to not knowing the applicant well enough. Attach additional pages if
needed. Thank you again for your help.
Phone:
Your knowledge of the applicant
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
PERSONAL QUALITIES
How long have you known the applicant: Honesty
excellent
poor
What is your relationship to the applicant? (eg teacher, employer etc)
Maturity
excellent
poor
Reliability
excellent
poor
Punctuality
excellent
poor
Grooming
excellent
poor
Tolerance
excellent
poor
Enthusiasm
excellent
poor
Acceptance of responsibility
excellent
poor
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
INTERPERSONAL SKILLS
Relationship with peers
excellent
poor
Please indicate your assessment of the applicant’s knowledge of the
Treaty of Waitangi in New Zealand society:
Relationship with people in authority excellent
poor
Cooperation with others
excellent
poor
Appreciation of equity issues (eg, sexism,
racism, disabilities, etc) excellent
poor
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
COMPREHENSION SKILLS
If you are aware of any disabilities/health problems that the applicant
has, please indicate what these are:
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
ATTITUDE TO WORK/STUDY
Programme of study: Study location: Reading skills
excellent
poor
Perseverance
excellent
poor
Written communication
excellent
poor
Application to work
excellent
poor
Numeracy skills
excellent
poor
Acceptance of help
excellent
poor
Verbal communication skills
excellent
poor
Initiative
excellent
poor
Listening skills
excellent
poor
Information seeking
excellent
poor
Computer-assisted communication
excellent
poor
Please comment on the applicant’s ability to succeed in the programme
of study applied for.
Summarise your assessment of the applicant and provide any further
details you feel would support this application:
Please provide your assessment of the qualities and skills of the
applicant, and how these may equip the applicant to be successful in
their chosen profession:
Final recommendation
I whole-heartedly recommend this applicant for the programme of
study applied for.
Would you be happy if the applicant provided their professional service
to you or one of your family members? (ie your child. Why or why not?)
I recommend this applicant although I have some reservations.
I have reservations in recommending this applicant, and can be
contacted to discuss this.
I believe this applicant is unsuitable for the programme of study
applied for.
This Reference is supplied on the understanding that it is confidential to
those involved in the selection process.
How do you believe the applicant will succeed within their professional
environment (ie classroom, hospital or unit)?
Referee’s name: Phone:
Email:
Referee’s signature:
Day
Month
Year
Date:
Once again, thank you for taking the time to complete this Reference. We
value your input into our selection process. Please return this completed
form within 14 days of receiving it via either:
zzEmail to [email protected] (as a scanned PDF of the
completed and signed document)
or:
zzPost to:
Academic Services, Massey University
Private Bag 11222, Palmerston North 4442
REFEREE’S REPORT
The purpose of this Reference is to support students applying for
selected entry programmes of study at Massey University.
Applicant’s details (to be completed by the applicant)
This form will remain confidential to members of the selection team.
Surname:
Thank you for acting as a referee for the applicant named to the right.
Your assistance will help us assess the applicant’s suitability for their
proposed programme of study at Massey University. It would be greatly
appreciated if you could fill out this Reference and return it within 14
days of receiving it from the applicant via either:
Forename:
zzEmail to [email protected] (as a scanned PDF of
the completed and signed document), or:
zzPost to:
Academic Services, Massey University
Private Bag 11222, Palmerston North 4442
Day
Month
Year
Date of birth:
Student ID:
(if known)
Email:
Please complete this Reference if you have known the applicant for one
year or more in the capacity of employer, educator, work colleague or
person of community standing, ie Kaumatua, Minister or similar. Please
do not complete this form if you are a flatmate, friend or relative of the
applicant, or if you are unable to provide the requested information due
to not knowing the applicant well enough. Attach additional pages if
needed. Thank you again for your help.
Phone:
Your knowledge of the applicant
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
PERSONAL QUALITIES
How long have you known the applicant: Honesty
excellent
poor
What is your relationship to the applicant? (eg teacher, employer etc)
Maturity
excellent
poor
Reliability
excellent
poor
Punctuality
excellent
poor
Grooming
excellent
poor
Tolerance
excellent
poor
Enthusiasm
excellent
poor
Acceptance of responsibility
excellent
poor
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
INTERPERSONAL SKILLS
Relationship with peers
excellent
poor
Please indicate your assessment of the applicant’s knowledge of the
Treaty of Waitangi in New Zealand society:
Relationship with people in authority excellent
poor
Cooperation with others
excellent
poor
Appreciation of equity issues (eg, sexism,
racism, disabilities, etc) excellent
poor
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
COMPREHENSION SKILLS
If you are aware of any disabilities/health problems that the applicant
has, please indicate what these are:
PLEASE INDICATE YOUR ASSESSMENT OF THE APPLICANT’S
ATTITUDE TO WORK/STUDY
Programme of study: Study location: Reading skills
excellent
poor
Perseverance
excellent
poor
Written communication
excellent
poor
Application to work
excellent
poor
Numeracy skills
excellent
poor
Acceptance of help
excellent
poor
Verbal communication skills
excellent
poor
Initiative
excellent
poor
Listening skills
excellent
poor
Information seeking
excellent
poor
Computer-assisted communication
excellent
poor
Please comment on the applicant’s ability to succeed in the programme
of study applied for.
Summarise your assessment of the applicant and provide any further
details you feel would support this application:
Please provide your assessment of the qualities and skills of the
applicant, and how these may equip the applicant to be successful in
their chosen profession:
Final recommendation
I whole-heartedly recommend this applicant for the programme of
study applied for.
Would you be happy if the applicant provided their professional service
to you or one of your family members? (ie your child. Why or why not?)
I recommend this applicant although I have some reservations.
I have reservations in recommending this applicant, and can be
contacted to discuss this.
I believe this applicant is unsuitable for the programme of study
applied for.
This Reference is supplied on the understanding that it is confidential to
those involved in the selection process.
How do you believe the applicant will succeed within their professional
environment (ie classroom, hospital or unit)?
Referee’s name: Phone:
Email:
Referee’s signature:
Day
Month
Year
Date:
Once again, thank you for taking the time to complete this Reference. We
value your input into our selection process. Please return this completed
form within 14 days of receiving it via either:
zzEmail to [email protected] (as a scanned PDF of the
completed and signed document)
or:
zzPost to:
Academic Services, Massey University
Private Bag 11222, Palmerston North 4442
CONSENT TO DISCLOSURE (FOR A NEW ZEALAND POLICE VET CHECK) One of the requirements of entry into the programme of study you are applying for is a criminal record check (under the Criminal Records [Clean Slate] Act 2004). Please note for all Social Work Qualifications we will be requesting a vetting check under the Exception clause of the Criminal Records (Clean Slate) Act 2004. The following NZ Police Vetting Service Request and Consent form needs to be completed, signed and returned to Massey University for processing. A trusted referee must sight at least two forms of ID, one of which must be photographic. Your referee must verify the photo against the applicant in person and sign the photocopy of the photo ID eg passport, driver’s license. This must be attached to your completed form and mailed or delivered to the university. Please print the ‘Request and Consent’ form and complete the steps below. Step 1: APPLICANT to complete Page 1 Enter your name at the top of the page and complete section 1 ‘Applicants role – purpose of vet’ Page 3 Enter ‘Massey University’ at the top of the page and complete section 2 ‘Personal information’ Page 4 Read the ‘Consent to disclosure’ and sign the bottom of the page Step 2: REFEREE to complete Page 2 Mark the box for part [B] ‘A Trusted Referee* has’ Please note: Do not complete the checklist at the bottom of page 2 – this is for processing staff only. Step 3: Mail the completed consent form and the verified photographic ID to: Academic Support Massey University Private Bag 11222 Palmerston North 4442 OR drop it in to your nearest Massey University Campus Information Centre Step 4: Document Checklist o
o
Request and consent form Verified photo ID NZPVS-­‐R+C -­‐ 08/14 Vetting Service Request and Consent Form
Name of Applicant to be vetted: Name of Approved Agency submitting vetting request: Massey University -­‐ Agency Code M70829, M70119, M70120 Section 1: Approved Agency to complete APPLICANT’S ROLE – PURPOSE OF VET Employee Contractor/consultant Volunteer Licence/Registration Other: (please specify here) Is this a renewal check? Yes No Description of role / licence / registration (e.g. caregiver; cleaner; taxi driver; teacher; etc): Role location (e.g. home; office; school; etc): Contact with vulnerable groups: Contact with children/youth Contact with vulnerable adults (aged, disabled) Application of clean slate: Type of contact: Level of contact: Supervised High Unsupervised Occasional To enable NZ Police to assess whether an exception applies to the general effect of the clean slate scheme on an eligible individual under the Criminal Records (Clean Slate) Act 2004, I declare my belief as follows: The role does not fit the criteria in section 19(3) of the Criminal Records (Clean Slate) Act
• e.g. teacher, doctor/nurse, rest home carer, school janitor
[Section 16] – Criminal convictions will not be released
IF the applicant is eligible for clean slate.
Clean Slate
OR The role fits the criteria of one or more of the exceptions in section 19(3) of the Criminal Records
(Clean Slate) Act
• e.g. it is a role predominantly involving the care and protection of, but not predominantly
involving the delivery of education to, a child or young person (e.g. caregiver,
nanny/crèche worker, foster/homestay parent, applicant for adoption) [section 19(3)(e)].
Exception
[Section 19(2)] – All criminal convictions will be released
EVEN IF the applicant is eligible for clean slate.
For information on the clean slate regime, see http://www.justice.govt.nz/services/criminal-records/about-the-criminalrecords-clean-slate-act-2004.
Page 1 of 4 NZPVS-­‐R+C -­‐ 08/14 Vetting Service Request and Consent Form
Section 1 continued: Approved Agency to complete EVIDENCE OF IDENTITY (ID) -­‐ for further information, see http://www.dia.govt.nz/Resource-­‐material-­‐Evidence-­‐of-­‐Identity-­‐Standard-­‐Index I confirm that the identity of the applicant has been checked by [A] or [B] as follows: [A] I have OR [B] A Trusted Referee* has sighted the ID documents below, and verified the photo against the applicant in person (mark box) Primary ID document (e.g. passport, original birth certificate, etc) and Another form of ID (e.g. driver licence, firearms licence, 18+ card, Community Services Card, etc) and One of the above must be photographic – confirm comparison made and, if applicable Evidence of name change where names differ (e.g. marriage/civil union certificate, statutory declaration, etc) [*a trusted referee must be over 16, have known the applicant for at least 12 months, and not be related, or a partner/spouse, or a co-­‐resident of applicant, and be either registered with the Approved Agency or a person of standing in the community (e.g. registered professional, religious or community leader). The trusted referee must sign a copy of the photo ID and provide his or her name and contact details.] Optional additional check by me (if appropriate) A search of our records to verify uniqueness (especially for professional bodies) CHECKLIST In making this request, I confirm that: I have complied and will comply with the Approved Agency Agreement (or existing Memorandum of Understanding) between NZ Police and the Approved Agency I represent; I am satisfied as to the correctness of the Applicant’s identity; and I have obtained the signed consent of the Applicant, as set out in section 2 of this form, to submit this vetting request. Approved Agency Authorised Representative: Name: Signature: Page 2 of 4 Date: NZPVS-­‐R+C -­‐ 08/14 Vetting Service Request and Consent Form
Name of Approved Agency submitting vetting request: Applicant to complete and return to Approved Agency Section 2: (the Approved Agency will submit the vetting request to NZ Police and receive the vetting result) PERSONAL INFORMATION Details (note: the name you are most commonly known by is your primary name) Family name: (Primary) Gender: Place of birth: NZ Driver Licence number: First name(s): (Primary) Date of birth: (dd/mm/yyyy) (town/city/state) (M) (F) (Other) Place of birth: (country) (for ID verification by NZ Police – optional) Passport number: (if held) Only for 'Additional Authorisation' -­‐ see page 4 Country of issue: If applicable, please include other names and mark them A, M, or P as appropriate: (A) alias or alternate name(s) (M) married name if not primary name (P) previous/maiden/name changed by deed poll or statutory declaration Family name: (A) (M) (P) Family name: Family name: (A) (M) (P) (A) (M) (P) Family name: (A) (M) (P) Permanent New Zealand Residential Address Number/Street: Suburb: City/Town/ Rural District: First name(s): First name(s): First name(s): (A) (M) (P) (A) (M) (P) (A) (M) (P) First name(s): (A) (M) (P) Page 3 of 4 Post Code: Period of Residence: NZPVS-­‐R+C -­‐ 08/14 Vetting Service Request and Consent Form
Section 2: continued Applicant to complete and return to Approved Agency (the Approved Agency will submit the vetting request to NZ Police and receive the vetting result) CONSENT TO DISCLOSURE (for a New Zealand Police Vet Check) -­‐ for further information, see http://www.police.govt.nz/advice/businesses-­‐and-­‐organisations/vetting I acknowledge and understand as follows: 1. The information about me that NZ Police may consider relevant to my application and release in vetting comprises any conviction history and, for certain agencies, infringement/demerit reports; and it may include other information such as active charges and warrants to arrest, any information received or obtained by NZ Police, and any interaction I have had with NZ Police in any context (including family violence), even where I have not been charged, or charges are withdrawn, or I have been acquitted (not guilty) of a charge, or I have been discharged without conviction. 2. Any conviction history will be released in accordance with the Criminal Records (Clean Slate) Act 2004; this means that, if I am ‘eligible’ for clean slate (e.g. no convictions for 7 years, never been to prison, no convictions for specified sexual offending, etc – see section 7 of the Act): a) my criminal record of convictions will not be disclosed; but b) if the role for which I have applied is an exception to the clean slate scheme (e.g. predominantly involving care and protection of a child or young person), my criminal record of convictions will be disclosed. 3. When releasing information to non-­‐government Approved Agencies, Police may release the fact, without details, that suppressed information exists in relation to any conviction and, where NZ Police considers it relevant and justified, in relation to any current or past charge however it was resolved (e.g. withdrawn, discharged, acquitted). 4. Where NZ Police holds relevant information that it is unwilling to disclose to the Approved Agency for privacy, confidentiality or law enforcement reasons, NZ Police may recommend against unsupervised access to children or vulnerable persons (this is known as a ‘red stamp’). 5. The personal information I provide in this form is being collected for vetting purposes, and may also be used for the purpose of updating NZ Police records. 6. I may withdraw this consent, prior to Police’s disclosure of the vetting result, by notifying the Approved Agency who will immediately notify NZ Police to cease the vetting process. 7. I am entitled to access the vetting result released to the Approved Agency and seek correction of Police information about me in accordance with the Privacy Act 1993. By making a request to the 'Approved Agency' within 20 working days of submitting this 'Request and Consent' form. 8.
No later than three months after the conclusion of the vetting process, the Approved Agency will securely dispose of this consent form and copies of identification documents, as well as the vetting result released by NZ Police, in accordance with the Privacy Act 1993 or, if applicable, the Public Records Act 2005 or any other enactment. 9. The information I have provided in this form relates to me and is correct. Authorisation I authorise NZ Police to disclose any personal information it considers relevant to my application (as described above) to the Approved Agency making this request for the purpose of assessing my suitability. Additional Authorisation [cross out or strike through this additional authorisation below if not applicable] Where the Approved Agency requesting a vet is a NZ Police business group (e.g. vetting for contractors to NZ Police; workers at major security events) I also authorise: • NZ Police to disclose the information on this form to, and access information from, other government agencies; and • NZ Police to disclose to my employer or other relevant agency its assessment regarding my suitability (only to the extent that I am approved or not approved as suitable, without reasons). Signature of applicant Page 4 of 4 Date: