Change of Circumstance form
As a national security clearance holder you must notify your organisation of
any changes to your circumstances. This form should be completed as soon
as possible after a change in circumstance that could impact on you as a
Please describe the details of the change to your circumstances. If you are in a new relationship, please fill in the new partner section
on the following page.
Type of change
(Please select from dropdown)
Has your manager been notified? Yes No
*For any changes to Citizenship please notify NZSIS Vetting.
What date is the change effective from?
Please describe the details of the change in circumstances.
Please describe the mitigation you are planning to put in place (if applicable).
Citizenship or Nationality*