Manager’s Certificate
Sale and Supply of Alcohol Act 2012
The following must be included in your application or it will be returned
Please tick when completed:
Completed application form
Prescribed fee $316.25
A copy of identification (NZ driver’s licence, passport, birth certificate)
A copy of your valid New Zealand work visa (if applicable)
A copy of your Licence Controller Qualification
One recent written work reference that provides evidence of your character, reputation, duties and responsibilities. The reference
must be signed and dated.
The application fee is non-refundable
Further information may be requested by the Secretary after the application has been received
Applicants must be at least 20 years old, have 6 months recent experience in a licensed premises, and currently working in a
licensed premises
Each applicant may be contacted by an inspector for an interview, which will include a test on the
Sale and Supply of Alcohol Act 2012
The application must be signed by the applicant.
The Manager’s Certificate fee of $316.25 is non-refundable.
ffice Use Only
Payment received:
/ /
Manager’s Certificate
Sale and Supply of Alcohol Act 2012
To: The Secretary
District Licensing Committee
(Please tick one)
South Wairarapa
Applicant Details
b) State all criminal convictions (other than convictions for offences against provision of the Land Transport Act 1998 not contained in
6, and offences to which the Criminal Records (Clean Slate) Act 2004 applies):
No criminal convictions
Convictions - list here:
) L
ist any experience (in particular, recent experience) working at any licensed premises or conveyance:
Premises Position Start date / End date
Preferred means of formal contact
Mail Email
Full name
Postal address
Residential address
Male Female
Date of Birth
Name of current workplace
Drivers Licence No. or Passport No.
a) Personal and contact details:
Applications must be submitted to the relevant local council:
District Licensing Committee
Masterton District Council
PO Box 444
Masterton 5840
T 06 370 6300
District Licensing Committee
Carterton District Council
PO Box 9
Carterton 5743
T 06 379 4030
District Licensing Committee
South Wairarapa District Council
PO Box 6
Martinborough 5741
T 06 306 9611
1. If the applicant intends to be the manager of any particular licensed premises, the Managers’s Certificate application must be filed with
the Secretary of the District Licensing Committee that approved the licence.
2. In all other cases, the application should be filed with the Secretary of the District Licensing Committee in the district where the applicant
3. The New Zealand Police are required by the Sale and Supply of Alcohol Act 2012 to make enquiries into the suitability of the applicant.
This will involve the police informing the District Licensing Committee of any convictions or concerns involving the applicant. Should there
be any concerns, the applicant will also be informed.
Personal information contained in your application and any supporting information will be held by the District Council. As part of the
licensing process the information will be provided to the District Licensing Committee, Police, licensing inspectorate, and possibly the
licensing authority. Personal information and supporting information may be included in the District Licensing Committee’s decision
which will be made publicly available. Any member of the public may request an extract from records and registers held by the
Council. These requests are subject to the Local Government Official Information and Meetings Act 1987.
d) Licence Controller Qualification issued (date)
e) Name of the licensed premises where you intend to be duty manager?
f) If a club, what will be the extent of your involvement in the management and activities?
Dated this ________________ day of _____________ 20_______
Signature of Applicant ____________________________________