Checklist
Renewal of Manager’s Certificate
Sale and Supply of Alcohol Act 2012
The following must be included in your application or it will be returned
Fees
The Manager’s Certificate fee of $316.25 includes GST and is non-refundable.
O
ffice Use Only
Notes:
Payment received:
/ /
If your Manager’s Certificate has expired, it cannot be renewed. You must apply for a new Manager’s Certificate.
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 permit (if applicable)
A copy of your current Manager’s Certificate (if the current certificate was not issued by the district you are applying to)
A copy of your Licence Controller Qualification
A copy of your Licence Controller Qualification Bridging Test Certificate
Notes:
The application fee is non-refundable
The LCQ bridging test is available at www.hsi.co.nz/lcqs/bridgingtest at no cost
Further information may be requested by the Secretary after the application has been received
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
Application
Renewal of Manager’s Certificate
Sale and Supply of Alcohol Act 2012
To: The Secretary
District Licensing Committee
(Please tick one)
Carterton
Masterton
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
Part 6, and offences to which the Criminal Records (Clean Slate) Act 2004 applies):
No criminal convictions
Convictions - list here:
c) What steps has the applicant taken to manage the sale and supply of alcohol with the aim of contributing to the reduction of
alcohol-related harm?
NCS No.
Preferred means of formal contact
Mail Email
a) Full name
Postal address
Telephone
Email
Mobile
Residential address
Male Female
Date of Birth
Name of current workplace
Drivers Licence No.
or
Passport No.
2
Applications must be submitted to the relevant local council:
District Licensing Committee
Masterton District Council
PO Box 444
Masterton 5840
T 06 370 6300
E alcohol@mstn.govt.nz
www.mstn.govt.nz
District Licensing Committee
Carterton District Council
PO Box 9
Carterton 5743
T 06 379 4030
E health@cdc.govt.nz
www.cdc.govt.nz
District Licensing Committee
South Wairarapa District Council
PO Box 6
Martinborough 5741
T 06 306 9611
E health@swdc.govt.nz
www.swdc.govt.nz
e) If you hold the Licence Controller Bridging Test Certificate, date issued:
f) Current Manager’s Certificate number
Expiry date
NOTES:
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
resides.
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.
PRIVACY STATEMENT:
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)
Dated this ________________ day of _____________ 20_______
Signature of Applicant ____________________________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome