Fillable Employer Accreditation Application (Accident Compensation Corporation New Zealand)

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Employer Accreditation Application (Accident Compensation Corporation New Zealand)

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OFFICE USE ONLY Client no.: Date received: / / Application no.:
November 2017
immigration.govt.nz
Employer Accreditation
Application
INZ 1090
Under Talent (Accredited Employers) Work Instructions
Information for employers
The objective of the Talent (Accredited Employers) Work Instructions is to allow accredited employers to supplement
their own New Zealand workforce in their core area of business activity through:
• the recruitment of workers who are not New Zealand citizens or residence class visa holders whose talents are
required by the employer; and
• the accredited employer having direct responsibility for those employees and their work output.
What is an ‘accredited employer’?
An accredited employer is an employer who is accredited by Immigration New Zealand (INZ) to employ persons
under the Talent (Accredited Employer) work instructions.
Who can get work visas under the Talent (Accredited Employers) Work Instructions?
Applicants can get a work visa under these instructions if they are non-New Zealand citizens or residence class visa
holders who:
• hold an offer of employment (see over page) from an accredited employer
• are aged 55 years or under
• meet immigration health and character requirements, and
• are bona fide applicants intending to comply with their visa conditions.
Applicants must apply at any onshore or offshore receiving office of INZ and meet the relevant application
requirements (completed application form and photos, fee and immigration levy, passport, acceptable medical and
X-ray certificates, police certificates, an employment offer from an accredited employer, and any other documents
or information required by the application form or INZ). See the Work Visa Guide (INZ 1016) for details.
What can Talent work visa holders do?
Persons granted Talent (Accredited Employer) work visas are granted multiple entry work visas enabling a stay of
30months in New Zealand. Their visas are subject to the condition that they may work for an accredited employer only.
Holders of these visas may apply for New Zealand residence after two years. They will qualify for residence if they:
• have been employed in New Zealand by an accredited employer (or any other employer they have been granted a
variation of conditions to work for) throughout a period of at least 24 months during the currency of their work visa.
• have full-time ongoing employment with a minimum base salary of NZ$55,000; and meet standard residence
application requirements, health and character requirements as well as any applicable occupational registration
requirements. See our Self-Assessment Guide for Residence in New Zealand (INZ 1003) for details.
2 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.
Applications for employer accreditation
Applications for employer accreditation must be made on this form and be accompanied by the application fee
(see our Fees Guide (INZ 1028)). Completed applications should be sent to: Business Migration Branch, Immigration
New Zealand, PO Box 27149, Wellington.
Accreditation criteria
For an employer to qualify for accreditation, INZ must be satisfied that the employer:
• is in a sound financial position
• has human resource policies and processes of a high standard
• has a demonstrable commitment to training and employing New Zealanders, and
• has good workplace practices – including a history of compliance with all immigration and employment laws and
policies such as the Immigration Act 2009, the Accident Compensation Act 2001, the Minimum Wage Act 1983,
the Health and Safety in Employment Act 1992, the Employment Relations Act 2000, Wages Protection Act 1983,
Parental Leave and Employment Protection Act 1987 and the Holidays Act 2003.
Accreditation assessment
When deciding whether to grant accreditation, INZ will consider all the information and evidence supplied in the
employer’s application for accreditation, and will take into account such factors as:
• the period for which the employer has been a going concern
• whether the employer has engaged with any relevant Industry Training Organisation (ITO)
• whether the employer is a member of the EEO Employers Group
• whether the employer is International Organisation for Standardisation “ISO-certified”
• whether the employer has an intention to maintain accreditation throughout the period of currency of any visas
granted to their employees under the Talent (Accredited Employers) Work Instructions.
INZ is required by the Talent (Accredited Employers) Work Instructions to be satisfied that all the information and
documents included in an application for employer accreditation are genuine and accurate, and may take any steps it
considers necessary to verify such information or documents, including interviews. It may also, where necessary, seek
the approval of an employer to conduct a site visit to the employer’s premises. (Where any information is identified by
the employer as commercially sensitive, and is provided to INZ in confidence, INZ will seek the consent of the employer
for the disclosure of that information.)
INZ will consult with relevant unions and other employee representatives when determining whether the
employer has human resource policies and processes of a high standard, a commitment to training and employing
New Zealanders, and good workplace practices.
Employers must consent to INZ seeking information from other groups within the Ministry of Business, Innovation
and Employment, WorkSafe New Zealand, and the Accident Compensation Corporation concerning the employer’s
compliance with New Zealand’s employment laws. Where such consent is not given, the application for accreditation
will be declined.
Offers of employment by accredited employers
Offers of employment made by accredited employers to non-New Zealand workers under the Talent (Accredited
Employers) Work Instructions must be:
• for genuine employment in New Zealand in the capacity or position stated
• for employment in the accredited employer’s core area of business activity and where the employer will have
direct responsibility for the employee’s work output
• for a position with a salary of NZ$55,000 or more
• for a period of at least 24 months
• for full-time employment (that is, amounting to, on average, at least 30 hours per week)
• current at the time the holder’s work visa application is assessed, and at the time he or she is granted a multiple
entry work visa
Employer Accreditation Application – November 2017 – 3
When filling in this form, please print clearly using CAPITAL LETTERS.
• compliant with all relevant employment law
1
in force in New Zealand, and
• when submitted by the holder to INZ, accompanied by evidence of full or provisional registration (or of eligibility
for such registration) if registration is required by law for that person to take up the offer. For medical practitioners,
registration within a ‘special scope of practice’ is not full or provisional registration for the purpose of a work to
residence application.
Note: the minimum base salary requirement of NZ$55,000 may be waived for applicants who produce evidence which satisfies INZ that they have
exceptional talent in a field of art, sport or culture as defined in our Work Visa Guide (INZ 1016).
Accreditation may be refused or revoked
An employer’s application for accreditation will be declined if an employer does not meet the criteria for accreditation,
or if INZ considers that accrediting that employer would create unacceptable risks to the integrity of New Zealand’s
immigration or employment laws or policies.
Accreditation may be revoked or not renewed if:
• as a result of an audit, an immigration officer is not satisfied that the requirements of accreditation continue to
bemet
• an employer fails to comply with a request for further information or records by INZ within a reasonable specified
timeframe
• INZ considers an employer’s conduct has created an unacceptable risk to the integrity of New Zealand’s immigration
or employment laws or policies
• an employer supplies false or misleading information to INZ.
Applications for reconsideration
There is no statutory right of appeal against a decision by INZ to decline an application for accreditation, however
INZ will reconsider a decline decision if the employer provides new information within 14 days of being notified
of the decision. Any application for reconsideration must be made in writing and must be accompanied by the
reconsideration fee. INZ’s decision on a reconsideration is final.
Importance of complying with all employment and immigration law
Employers whose conduct results in their accreditation being revoked or not being renewed, may jeopardise the ability
of any employees holding work visas to subsequently apply for residence under the Talent (Accredited Employers)
Residence Instructions.
Immigration Advisers Licensing Act 2007
Under the Immigration Advisers Licensing Act 2007 it is an offence to provide immigration advice without being
licensed or exempt. If your immigration adviser is not licensed when they should be, Immigration New Zealand will
return your application.
For more information and to view the register of licensed advisers, go to the Immigration Advisers Authority website
www.iaa.govt.nz or email info@iaa.govt.nz.
Work entitlement
It is an offence under the Immigration Act 2009 to employ a person who is not entitled to work in New Zealand.
One way for employers to avoid committing this offence is to check a person’s entitlement to work through
Immigration NewZealand’s online VisaView system. For more information or to register please visit
www.immigration.govt.nz/visaview. Disclosure of information through VisaView is authorised by legislation.
When filling in this form, please print clearly in English using CAPITAL LETTERS.
Detach and retain pages 1 to 4, if desired.
1 Compliance with relevant New Zealand employment law includes but is not limited to:
• a written employment agreement that contains the necessary statutory specified terms and conditions
• meeting holiday and special leave requirements and other minimum statutory criteria
• meeting occupational safety and health obligations.
4 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.
OFFICE USE ONLY Client no.: Date received: / / Application no.:
November 2017
immigration.govt.nz
Employer Accreditation
Application
INZ 1090
Under Talent (Accredited Employers) Work Instructions
When filling in this form, please print clearly using CAPITAL LETTERS.
Are you applying for renewal of your existing accreditation?
Yes (if yes, provide your most recent accreditation approval number) 
No
Section A
Employer details
This form must be completed and signed by a person who has authority to make representations and enter into
agreements on the employer’s behalf. Please answer all questions. If any question does not apply please answer
“N/A” for “not applicable”.
A1
Employer’s name
A2
Employer’s legal status
(eg limited liability company,
sole trader, partnership)
A3
New Zealand Business Number
For help search: www.nzbn.govt.nz
A4
Name of person completing this application for accreditation
Family/last name Given/first name(s)
A5
Position or title
A6
Employer’s contact details.
Name of contact person if different from that given at
A3
Company name (if applicable) and physical and postal addresses
Telephone (daytime) Telephone (evening)
Fax
Email
Website
6 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.
A7
Name and address for communication about this application
Same as address at
A6
or
Other Give details below
Name of contact person
Organisation name (if applicable) and address
New Zealand Business Number (for New Zealand businesses only)
For help search: www.nzbn.govt.nz
Telephone (daytime) Telephone (evening)
Fax
Email
A8
Do you authorise the person stated at
A7
to act on your behalf?
Yes
No
A9
Do you authorise all other licensed immigration advisers or persons exempt from licensing who work for the
organisation named at
A7
to act on your behalf (if applicable)?
Yes Note: the person identified at
A7
will receive all communication from Immigration New Zealand.
No Only the person indicated at
A7
may act on my behalf.
A10
Have you received immigration advice on this application?
Yes Please make sure that your immigration adviser completes Section I: Immigration adviser’s details.
No
You can find a definition of immigration advice at www.immigration.govt.nz/advice
A11
If your application for accreditation is approved, do you wish your contact details to be published on the list of
accredited employers on the INZ website at no cost to you?
Yes
No
Section B
Employer’s need for accreditation
B1
Why are you seeking employer accreditation?
Current need to recruit offshore for talented staff
Anticipate future need to recruit offshore for talented staff
Seeking accreditation to enable fast track offshore recruitment of talent should the need arise
Other reason – or any additional comments if desired.
B2
How many non-New Zealand workers are you likely to recruit in the accreditation period (if known)?
B3
If your application for accreditation is approved, do you intend to maintain your employer accreditation for the
period of currency of any work visas granted to any of your employees under the Talent (Accredited Employers)
Work Instructions?
Yes
No
Employer Accreditation Application – November 2017 – 7
When filling in this form, please print clearly using CAPITAL LETTERS.
B4
Specify the roles you are intending to fill as an accredited employer.
Section C
Employer’s business details
C1
How many years has the business been operating?
C2
Number of current employees (including management)
C3
Number of employees who are New Zealand citizens or residence class visa holders
C4
If you are renewing your accreditation and there has been a significant reduction in the number of employees,
please explain the reason for this reduction.
C5
Industry sector
Accounting/Finance
Engineering & Science
Information Technology
Sales & Marketing
Administration & Customer Service
Film/Video
Legal
Sports
Advertising, Media, PR
Government (central)
Manufacturing
Telecommunications
Agriculture, Forestry & Fishing
Government (local)
Restaurant/Catering
Tourism & Accommodation
Arts/Cultural/Entertainers
Healthcare
Retail
Water, Gas, Electricity
Education & Training
Human Resources
Other (please specify)
C6
Please give brief details of your business (if further details are given in a separate document please state this).
Type of business
Products or services
C7
Does your business have any partnerships with overseas businesses?
Yes
Provide details of overseas businesses, including their location, activities, and nature of your business relationship
No
8 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.
Section D
Business record
D1
Is your business registered with the Companies Office?
Yes
No
D2
Have you, or any of the directors or managers of your business, ever been declared bankrupt?
Yes
Provide details including names, dates and when discharged.
No
D3
Have you or any of the directors or managers of your business ever been investigated by the Serious Fraud Office
or the New Zealand Police for any offences arising in the course of, or resulting from, business dealings?
Yes
Provide details including name, date and outcome and any penalty imposed and/or remedial action required.
No
D4
What evidence can you provide of your business record and financial position? (Where possible, information
supplied should cover at least two financial years. The more evidence you can enclose, the sooner INZ will be able
to complete its assessment of your application.)
Available Business record information available
Please tick to show whether information is available and whether evidence is enclosed with your
application. Where any information listed is contained in another document, please state this
(eg “See annual reports attached”).
Evidence enclosed
with application?
Startup company/new business – no evidence of established business record
Yes
No
Our business reputation and history in the marketplace as a successful established business
Yes
No
Annual reports
Yes
No
Business plans
Yes
No
Sets of accounts certified by an accountant
Yes
No
GST returns
Yes
No
Financial statements (profit and loss, cash flow, balance sheet)
Yes
No
Companies Office registration details, showing directors, shareholders etc
Yes
No
Other evidence (please specify below)
Yes
No
Employer Accreditation Application – November 2017 – 9
When filling in this form, please print clearly using CAPITAL LETTERS.
Section E
Human resources
E1
Have you attached an organisational chart showing the structure of your business, the number of people
employed, and the areas in which they are employed?
Yes
No
E2
Does your business have written human resource policies and/or procedures?
Yes
Attach evidence
No
E3
Who normally has overall responsibility for human resource or personnel matters in your business?
Name of person responsible
Position or title
E4
Who is normally responsible for staff recruitment in your business? (Eg yourself, human resource manager,
local managers, recruitment agency.)
E5
What checks will be carried out to verify information provided by foreign workers being considered for
employment in your business? (If staff recruitment is contracted to a recruitment agency, please state this and
attach a written statement from the recruitment agency describing what checks that agency will carry out on
your behalf.)
References/referees
Qualifications or training certificates
Section F
Workplace practices
F1
Has your business ever been found to be in breach of employment or labour law by the Ministry of Business,
Innovation and Employment, WorkSafe New Zealand, or by any New Zealand tribunal, authority or court?
(This includes any breaches of the Accident Compensation Act 2001, the Minimum Wage Act 1983, the Health
and Safety in Employment Act 1992, the Employment Relations Act 2000, Wages Protection Act 1983, Parental
Leave and Employment Protection Act 1987 and the Holidays Act 2003).
Yes
Give details including type of breach, date of notification (or date of tribunal, authority or court decision) and penalty imposed
or remedial action required. (If full details are set out in an attached document please state this.)
No
10 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.
F2
Has your business ever been found to be in breach of the provisions of the Immigration Act 2009 or the
Immigration Act 1987?
Yes Give details including: type of breach, date of notification by INZ (or date of court decision if convicted), penalty imposed or remedial
action required. (If details are set out in an attached document please state this.)
No
F3
Does your business have union representation in the workplace?
Yes
Provide details
No
Name of union Union’s contact details (if known)
Phone
Fax Email
As advised in the ‘Accreditation assessment’ section on page 2, Immigration New Zealand will consult with
relevant unions as part of the application process. It may be helpful if you inform the unions listed above that
you are applying for accreditation under the Talent (Accredited Employers) Work Instructions.
Section G
Training and employment of New Zealanders
You must provide evidence of your commitment to training and employing New Zealand citizens or residence
class visa holders.
G1
What training does your business provide to New Zealand employees? Support your statement with evidence – for example,
of any in-house training and development programmes, or involvement with any New Zealand Industry Training Organisation (ITO), or funding
of employees’ attendance at training courses by external training providers, and/or any other evidence that you consider demonstrates your
commitment to employing and training New Zealanders. (If details are set out in an attached document please state this.)
G2
What attempts to employ New Zealand citizens or residence class visa holders has your business made? Support
your statement with evidence - for example, dated copies of advertising, records of engagement with recruitment companies and/or Work
and Income. The evidence should show where advertising occurred, as well as the frequency and duration.
Employer Accreditation Application – November 2017 – 11
When filling in this form, please print clearly using CAPITAL LETTERS.
G3
Has the business made anybody redundant, or been through a consultation with respect to potential
redundancies, in the past 12 months?
Yes Provide details, including how many people were affected and their roles.
No
G4
Under the Talent (Accredited Employers) Work Instructions, INZ must seek information from the Ministry of
Business, Innovation and Employment’s employment relations and occupational health and safety services,
WorkSafe New Zealand and the Accident Compensation Corporation, concerning your compliance with
New Zealand’s immigration and employment laws.
Note: if you do not give your consent to INZ seeking this information from these agencies, your application for accreditation will be declined.
G5
Do you consent to INZ seeking information concerning your compliance with New Zealand’s immigration and
employment laws from the agencies listed above?
Yes
No
Section H
Declaration by employer
This section must be read and signed by a person who has authority to make representations and enter into
agreements on the employer’s behalf.
I understand the notes and questions in this form and I declare that the information given about my business is true
and correct.
I understand that if I make any false statements, or provide any false or misleading information, or have changed
or altered this form in any way, this application for accreditation may be declined, and that I may also be committing
an offence under sections 342 and 348 of the Immigration Act 2009 and may be liable to prosecution.
I understand that I am required to inform Immigration New Zealand about any relevant changes to the circumstances
of my business that occur after I lodge this application.
I declare that there are no matters or warrants outstanding, or investigations of any kind, which could have any
current or future effect on the ability of my business to honour its obligations as an accredited employer under the
Talent Work (Accredited Employers) Work Instructions.
I understand that if I have received immigration advice from an immigration adviser and if that immigration adviser
is not licensed under the Immigration Advisers Licensing Act 2007 when they should be, Immigration New Zealand
will return my application.
I authorise Immigration New Zealand to make any enquiries it deems necessary in respect of the documents or
information provided in respect of this application, and to share information provided about me or my business with
other government agencies (including overseas agencies) to the extent necessary to make decisions about whether
I qualify for approval as an accredited employer under the Talent (Accredited Employers) Work Instructions.
Note: where any information is identified by the employer as commercially sensitive and is provided in confidence to Immigration NewZealand, and
Immigration NewZealand considers that disclosure of that information is necessary for the processing of this application, it will seek the consent of
the employer for the disclosure of that information.
I accept that any advice given to me by Immigration New Zealand before lodging this application was intended to
assist me, and that acting on that advice does not mean that this application to be an accredited employer under
the Talent (Accredited Employers) Work Instructions will be approved.
Signature of employer
Date
D M Y YD M Y Y
Job title or position
12 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.
Section I
Immigration adviser’s details
This section must be completed by the employer’s immigration adviser.
If the employer has authorised all
advisers within an organisation to act on its behalf at
A8
, only the person named at
A6
must complete this
section. If the employer does not have an immigration adviser, this section does not have to be completed.
I1
Tick the one option that applies to you.
I am a licensed immigration adviser under the New Zealand Immigration Advisers Licensing Act 2007. Go to
I2
I am exempt from licensing under the New Zealand Immigration Advisers Licensing Act 2007. Go to
I3
If you are unlicensed when you should be licensed under the Immigration Advisers Licensing Act 2007, Immigration New Zealand will
return your client’s application. It is an offence to provide immigration advice without holding a licence, unless you are exempt.
I2
Licensed advisers. Provide your licence details.
Licence type
full
provisional
limited. List conditions specified in the register.
Licence number
0
2
Go to Section J: Declaration by person assisting the applicant.
I3
Exempt from licensing. Tick one box below to show why you are exempt from licensing.
I provided immigration advice in an informal or family context only, and I did not provide the advice
systematically or for a fee.
I am a New Zealand member of Parliament or member of their staff and I provided immigration advice
as part of my employment agreement.
I am a foreign diplomat or consular staff.
I am an employee of the New Zealand public service and I provided immigration advice within the scope
of my employment agreement.
I am a lawyer and I hold a current practising certificate as a barrister or as a barrister and solicitor of the
High Court of New Zealand.
I am employed by, or I am working as a volunteer for, a New Zealand community law centre where at least
one lawyer is on the employing body of the community law centre or is employed by or working as a volunteer
for the community law centre in a supervisory capacity.
I am employed by, or I am working as a volunteer for, a New Zealand citizens advice bureau.
Go to Section J: Declaration by person assisting the applicant.
Section J
Declaration by person helping the employer
This section must be completed and signed by the employer’s immigration adviser, or by any person who has
assisted the employer by providing immigration advice, explaining, translating, or filling in the form for the
employer. If the employer does not have an immigration adviser, and no one helped the employer to fill in this
form, this section does not have to be completed.
If you are unlicensed when you should be licensed under the Immigration Advisers Licensing Act 2007, Immigration New Zealand will return your
client’s application. It is an offence to provide immigration advice without holding a licence.
For more information, go to the Immigration Advisers Authority website www.iaa.govt.nz, or email info@iaa.govt.nz or write to them at
POBox6222, Wellesley Street, Auckland 1141, New Zealand.
Name and address of person assisting employer. 
Same as name and address given at
A6
, or 
as below.
Family/last name Given/first name(s)
This form has been approved under section 381 of the Immigration Act 2009
Employer Accreditation Application – November 2017 – 13
When filling in this form, please print clearly using CAPITAL LETTERS.
Organisation name (if applicable) and address
New Zealand Business Number (for New Zealand businesses only)
For help search: www.nzbn.govt.nz
Telephone (daytime) Telephone (evening)
Fax Email
I understand that after the employer has signed this form it is an offence for me to change or add further information,
or change or add any documents attached to the form, without making a statement identifying what information or
material has been changed, added or attached and by whom. If I make these changes or additions, I must state on the
form what they were, who made them and the reason they were made.
I understand that the maximum penalty for this offence is a fine of up to NZ 100,000 and/or a term of imprisonment
of up to seven years.
I certify that the employer asked me to help them complete this form and any additional forms. I certify that the
employer agreed that the information provided was correct before signing the declaration.
I have assisted the employer as an interpreter/translator.
I have assisted the employer with recording information on the form.
I have assisted the employer in another way.
Please specify
I have provided immigration advice (as defined in
the Immigration Advisers Licensing Act 2007) and
my details in Section I: Immigration adviser’s details are correct.
Signature of person assisting
Date
D M Y YD M Y Y
14 – Employer Accreditation Application – November 2017
When filling in this form, please print clearly using CAPITAL LETTERS.When filling in this form, please print clearly using CAPITAL LETTERS.
About the information you provide
Deciding whether you are eligible to become
an accredited employer
Immigration New Zealand collects the information
about you on this form to decide whether you are
eligible to be an accredited employer under the Talent
(Accredited Employers) Work Instructions. We may
also use the information to contact you for research
purposes or to advise you on immigration matters.
The address of Immigration New Zealand is
POBox1473, Wellington 6140, New Zealand.
Do not send your application to this address.
Collecting the information is authorised by
the Immigration Act 2009 and the Immigration
Regulations made under that Act. You do not
have to provide the information, but if you do
not we are likely to decline your application.
Immigration New Zealand may also share the
information you have provided with other
government agencies that are entitled to it
by law, or with other agencies (as you have
agreed in the declaration).
You have the right to access the information
we hold about you and have any of it corrected
if you think it is necessary.
For more information
If you have questions about completing this form:
• see our website www.immigration.govt.nz
• telephone our call centre on 0508 558 855
(within New Zealand)
Application checklist
OFFICE
USE
ONLY
Information and documents you must supply
CHECK
LIST
I have read the declaration, and signed and dated the
application form.
I have enclosed the application fee or authorised
a credit card payment.
I have checked that all supporting documents required by
this form or indicated by me as being attached, are either
attached or enclosed for submission with the application.
Send your completed application to:
Business Migration Branch
Immigration New Zealand
PO Box 27149
Wellington 6141
New Zealand.
Employer Accreditation Application – November 2017 – 15
When filling in this form, please print clearly using CAPITAL LETTERS.When filling in this form, please print clearly using CAPITAL LETTERS.
Section K
Paying your application fee
See our Fees Guide (INZ1028) or our website
www.immigration.govt.nz/fees for more information
about current fees and payment methods.
Your application fee
Amount you are paying:
Amount
Currency
(eg. NZD, USD, RMB)
Application number
(office use only)
Preferred methods of payment
We recommend that you use one of the following methods
of payment for better security and faster processing:
Bank cheque/bank draft
Credit card* (choose one)
Mastercard
Visa
Name of cardholder
Card number
CVC/CVV number
Note: your CVC/CVV number is the three-digit number found
on the signature strip on the back of your credit card.
Expiry date
D M Y YD M Y Y
Signature of cardholder
Date
D M Y YD M Y Y
We do not accept money orders.
16 – Employer Accreditation Application – November 2017
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