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
clearance holder.
Personal Details
First name:
Organisation
Middle name(s):
Role/Title:
Family name:
Clearance level:
Date of Birth:
Situation Overview
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)
Other (please specify)
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).
Reporting date
Top Secret Special
Citizenship or Nationality*
Change in personal relationship
If you have a change in personal relationship please provide the following details.
First name:
Please send the completed form to your Chief Security Officer (CSO).
Risk Assessment (Security Officer to complete)
Is this change likely to undermine the clearance holder’s ability to protect protectively marked material? Yes No
What security risk, if any, may result from the subject continuing to have access to protectively marked material?
Security Officer name:
Email address:
Contact phone:
Other (please specify)
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