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F- Emergency Appointment (Ministry of Justice New Zealand)

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F - EMERGENCY APPOINTMENT – 2/05/2019
Emergency Appointment
PRIVATE SECURITY PERSONNEL LICENSING AUTHORITY
When to use this form
Use this form to notify the Licensing Authority of any emergency appointment(s) or apply to the Licensing
Authority to extend an emergency appointment, when the employee has previously been appointed as an
emergency appointment for a period of 2 weeks.
You can make an emergency appointment provided the following applies:
• The person you’re appointing must already have applied for a certificate of approval and paid the fee.
• You have a real need to engage an emergency appointee. This need will have arisen due to illness or
an emergency and you have insufficient staff who hold a certificate of approval.
• You should be satisfied that
o The person has no grounds for disqualification that apply to them
o The person is not currently charged with an offence that would be grounds for disqualification
if they were convicted
o To the best of your knowledge the information supplied in their application is true and correct
• The Licensing Authority has been notified before the emergency appointment has been made.
• The person has not been employed on an emergency appointment previously for a period of two
weeks or more (unless you have gained the approval of the Licensing Authority prior to making the
appointment).
Completing this form
• Print clearly in CAPITALS
• Use a black pen or blue pen to complete
this form
• Answer every question on the form unless
the instructions tell you otherwise
Payment information
There is no filing fee with this application.
Application process
In normal circumstances it will take 3 working days
to hear the outcome of your application.
Important information
If you provide false or misleading information to the
Licensing Authority, you may be liable for a fine of
up to $20,000 upon summary conviction.
You must immediately stop a person from
undertaking any work for which a certificate is
required if instructed in writing by the Licensing
Authority.
All personal information provided to the PSPLA will
be dealt with in accordance with the Privacy Act
1993.
F - EMERGENCY APPOINTMENT – 2/05/2019
Step 1. Application details
If you have a licence, what is your licence number?
Licence number:
If you are licensed and have entered your licence number above, move on to Step 2.
Please provide your full name below if you do not have a licence and employ crowd controller employees (crowd
controller employees are sometimes known as doormen or bouncers).
What is your name?
Full name
Middle
Step 2. Employee details
If you are completing this form on behalf of a company enter the company name here
Licence number:
What is the employee’s name you are appointing as an emergency appointment?
Full name
Middle
If you know your employees certificate of approval application number enter it here
Certificate of approval number:
If they’re known or previously known by another name(s), please fill in details below
Full name
Middle
Date of Birth
/
/
(day/month/year)
What is your gender? (Please tick to confirm)
Male
Female
What is your employees address for service?
Address
No.
Street
Suburb
City
State (if outside NZ)
Country
Post code
F - EMERGENCY APPOINTMENT – 2/05/19
Step 3. Emergency appointment details
Please give details of when the employee will be appointed as an emergency appointment. You may
only engage an employee as an emergency appointee for a maximum total time of 2 weeks. Any
additional period of time requires the Licensing Authority’s approval. The purpose of this form is to:
(Please tick to confirm)
Notify the Licensing Authority of an emergency appointment
Seek approval for an extension of an emergency appointment
What dates do you require this emergency appointment?
Emergency appointment start date
/
/
(day/month/year)
Emergency appointment end date
/
/
(day/month/year)
Please provide a description of the emergency situation below:
Has the employee previously been appointed as an emergency appointment for a total period of 2
weeks or more? (Please tick to confirm)
Yes
No
If yes, please supply the previous start and end dates. If no, leave this blank and move on to Step 4
Emergency appointment start date
/
/
(day/month/year)
Emergency appointment end date
/
/
(day/month/year)
Please advise why you require this employee to be appointed as an emergency appointment. State the
nature of the emergency:
F - EMERGENCY APPOINTMENT – 2/05/19
Step 4. Employer confirmation of accuracy
I confirm to the best of my knowledge that the employee named in this form does not meet the disqualification
criteria set out in section 62 of the Private Security Personnel and Private Investigators Act 2010, see
www.legislation.govt.nz for further details.
Name
Signature
Date
Step 5. Do a quick check
You have answered every relevant question in this form truthfully and correctly.
You have signed and dated this form
Step 6. Send in this form
You can fill in this form and email it to PSPLA@Justice.govt.nz
Or you can fill in this form and print and post it to:
Private Security Personnel Licensing Authority
SX 10042
Wellington
New Zealand
Address: Level 1, 86 Customhouse Quay, Wellington 6011
Phone: 04 462 477 752
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F- Emergency Appointment (Ministry of Justice New Zealand)

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Completed 29 March 2021

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