Fillable Application for Managers Certificate (Timaru District Council New Zealand)

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Application for Managers Certificate (Timaru District Council New Zealand)

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The Application for Managers Certificate (Timaru District Council New Zealand) form is 6 pages long and contains:

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  • 21 check-boxes
  • 46 other fields

Country of origin: NEW-ZEALAND
File type: PDF

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#954653
Application for Manager’s Certificate
Sale and Supply of Alcohol Act 2012 – Section 219
For office use:
Application no: ……………………………………………
Checked: ……………………………………………
Fee paid: $316.25
Receipt no: ……………………………………………
Police: ……………………………………………
Surname: ……………………………………………
Application for Manager’s Certificate #954653
Mackenzie, Timaru, Waimate District Licensing Committee Page 1
Application for Manager’s Certificate
Form 17
Section 219, Sale and Supply of Alcohol Act 2012
1. Details of Applicant
Applicant title: Mr Mrs Ms Miss
Other:
First name: Middle name:
Surname:
Any aliases:
Gender: Male Female
Occupation:
Date of birth: Place of birth:
Passport number: Drivers licence number:
Residential address:
Postal address (if difference from above):
Phone number: Work number:
Mobile number:
Email address:
2. Criminal Convictions
Have you ever been convicted of an offence (including traffic but not parking)?
Yes No
Note: As per the Criminal Records (Clean Slate) Act 2004, if you have no convictions in the
last 7 years, you need not declare any convictions prior to that date other than convictions
relating to imprisonment or indefinite disqualified from driving. Refer to
http://www.justice.govt.nz/privacy/clean-slate.html
If yes, give details:
Nature of offence:
Date of conviction:
Penalty suffered:
Application for Manager’s Certificate #954653
Mackenzie, Timaru, Waimate District Licensing Committee Page 2
Nature of offence:
Date of conviction:
Penalty suffered:
Nature of offence:
Date of conviction:
Penalty suffered:
3. Employment / Training Details
Name of licensed premised at which you are currently employed / volunteering:
Address of premises:
How long have you been employed at this premises:
What other experience do you have working in and / or controlling licensed premises:
Premise:
Position and duties:
Date employed:
Premise:
Position and duties:
Date employed:
Premise:
Position and duties:
Date employed:
Premise:
Position and duties:
Date employed:
Application for Manager’s Certificate #954653
Mackenzie, Timaru, Waimate District Licensing Committee Page 3
If you are employed / volunteering at a club, what is the extent of your involvement in the
clubs management activities:
Which organisation did you obtain your training through:
Polytech Online
Other (please name):
Do you hold the Licence Controller Qualification (LCQ): Yes No
If yes, on what date was that qualification obtained:
4. Signature and Date
I acknowledge that I understand my obligations as prescribed by the Sale and Supply of
Alcohol Act 2012:
Signature of applicant:
Position:
Date:
If this form is being completed online, you will not be able, or required to sign this
form and the online lodgement will be treated as confirmation of your
acknowledgement and acceptance of the above responsibilities and liabilities and
that you have made the above representations, warranties and certification.
When complete, please email this form to the email address below.
For assistance please contact:
Liquor Licencing
Timaru District Council
2 King George Place
PO Box 522
Timaru 7940
Lodgement Email: liquoradmin@timdc.govt.nz
Phone: 03 687 7200
Application for Manager’s Certificate #954653
Mackenzie, Timaru, Waimate District Licensing Committee Page 4
Payment of Fees
Please make payment at the time of lodgement to the following bank account:
Timaru District Council
02 0888 0269159 00
Reference: Mgr Cert
Particulars: Applicant name
Amount: $316.25
Notes
1 This application must be accompanied by the prescribed fee. Application fees are
set by the Ministry of Justice. For more information see www.justice.govt.nz
2 The New Zealand Police are required by the Sale and Supply of Alcohol Act 2012
to make inquiries into the suitability of the applicant. This will involve informing
the District Licensing Committee and the Alcohol Regulatory and Licensing
Authority of any convictions or concerns involving the applicant. Should there be
any concerns, the applicant will also be informed. By signing this form, you
consent to the release of this information.
3 Please note that a person may not be appointed as a manager of any licensed
premises unless the person is of or over the age of 20, and holds a manager’s
certificate (section 216 of the Sale and Supply of Alcohol Act 2012).
4 Each applicant is required to attend an interview with a licensing inspector,
which will include a test on the Sale and Supply of Alcohol Act 2012. You will be
contacted after your application has been received to arrange an appointment
for your interview.
Application for Manager’s Certificate #954653
Mackenzie, Timaru, Waimate District Licensing Committee Page 5
Checklist
Please read and complete this checklist BEFORE submitting the application.
Include with application form:
The original completed application.
Written evidence from the licensed premises supporting the applicant’s application.
You must be currently employed in the industry and have a minimum of six (6)
months experience in the liquor industry in New Zealand.
Written evidence of previous employment in the industry if less than six months
recent experience with current employer.
All criminal convictions must be disclosed. Recent criminal conviction(s) may lead to
the suspending or declining of this application.
Evidence of relevant training certificate (showing unit standards 4646 and 16706) and
Licence Controller Qualification (LCQ) Certificate.
If you were not born in New Zealand you must produce proof of your right to be
working in New Zealand by means of one of the following:
− Copy of valid passport with current work permit/visa
− Copy of granting of Permanent Residence for New Zealand
−
Copy of New Zealand Citizenship
Fee of $316.25 attached (cheques made payable to Timaru District Council). If you
wish to pay online please see information on the previous page.
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Application for Managers Certificate (Timaru District Council New Zealand)

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Completed 11 February 2021

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