Family/Last name(s)
Given/First name(s)
Other Names (e.g. birth name, unmarried name, name change, alias, English names if used etc)
Please tick: Mr
Town/City of birth
Country of birth
Birthdate (day, month, year)
Address: Street
Post Code
Telephone: Home
(Where certicate will be sent)
The fee for this application is NZ$112.40 (including GST). This application must be completed by the applicant unless s/he is under the age of 16 years.
If you are sending original documents in support of your application, for safest delivery, these should be sent by courier. The processing time for a correct
application is 15 working days and there is no urgent service.
Date of Grant (day, month, year)
Place of Grant
(Suburb, town, city)
Please enclose a fee of
NZ$112.40 per applicant.
Completed applications or any queries concerning New Zealand citizenship can be sent to:
Lodging an application
The Citizenship Office
Department of Internal Affairs
PO Box 10-680
Wellington, New Zealand
Applicants who are residing outside New Zealand may lodge their application at some
New Zealand High Commissions, Embassies or Consulates.
Information held by Citizenship can be used in authorised information matching programmes
by the Electoral Enrolment Centre, the Department of Internal Affairs, the Inland Revenue Department, the Land Transport New
Zealand, the Ministry of Education, the Ministry of Social Development and the Workforce Group (Immigration Services) as
authorised by statute. Details are available on the Internal Affairs website - www.dia.govt.nz or call 0800 22 5151
Collection and use of information provided in support of application
This application form requires you to produce certain information in support of your application. The decision to supply the
information is voluntary. If you do not produce sufcient information to enable a conrmation of New Zealand citizenship to be
determined, the application will be declined.
e collection of this information is required to see if the requirements of the Citizenship Act 1977 are met, to process the application
and for other lawful purposes. The information you provide in this form is collected and held by: Department of Internal Affairs,
PO Box 10-526, Wellington, New Zealand and the Ministry of Foreign Affairs and Trade.
You have a right of access to and correction of personal information you have provided under the Information Privacy
Principles of the Privacy Act 2020.
I declare that the statements made in this application are to the best of my knowledge true, complete and correct.
I understand that if false information has been provided any citizenship certicate issued on the basis of that information may
be cancelled and the matter referred to the New Zealand Police.
I conrm that I have read and understood the statement above relating to privacy.
I consent to information being obtained about me for the purposes of determining eligibility with respect to this application by
an authorised information matching programme in accordance with section 78A of the Births, Deaths and Marriages Act 1995.
I authorise any additional enquiries necessary for determining this application for conrmation of New Zealand citizenship.
Cheque / Bankdraft - Please make payable to “Department of Internal Affairs”
Please charge my: Mastercard Visa Expiry date:
Credit Card Number:
Print Full name
of Cardholder:
Amount: 
Please charge the return courier fee to my credit card
Tel: +64-4-474 8123
0800 22 51 51 (within New Zealand only)
Fax: +64-4-382 3561
Email: staykiwi@dia.govt.nz
Website: www.govt.nz/citizenship
If applicant is under 16 years of age the parent must sign this form.
Both photos must be the same in all aspects - two prints from the same negative
- taking care they are not damaged by staples, pins, paperclips, folding or ink.
Photos are required for  applicants.
recent, less than 6 months old
be a full front, close up view of the head and shoulders with the head covering
70% to 80% of the photograph
be taken with a neutral expression (not laughing or frowning) with your mouth
closed. Show you looking straight at the camera, and your head not tilted. Show
your eyes open and clearly visible, and no hair in your eyes
without sunglasses. Tinted prescription glasses may be worn as long as eyes are
still visible
a true image and not altered in any way
clear, sharp and in focus
with a plain light coloured background (not white)
be of good quality colour and on high quality paper, with no ink marks on the
image (no ink jet printers)
45mm x 35mm in size.
(Do not trim your photos)
 Businesses that specialise in taking passport size photos will
usually supply one with a preprinted label on the back. Contact the Citizenship
Ofcer if you require further information on photographic image requirements.
Surname or family name
Given or rst names
Date of Birth (day, month, year)
Surname or family name of applicant
Given or rst names of applicant
for years/months and can conrm their identity.
To act as a witness you must:
Signature of witness Date
Address: Street
Before submitting your application for a replacement certicate you are required to sign this statutory declaration and have it witnessed
by an authorised person.
Authorised” people include: Justices of the Peace, solicitors, Members of Parliament and New Zealand representatives overseas.
If you are under 16 years old your parent or guardian  on your behalf using their full name
 tick one
Solemnly, and sincerely declare that I believe the facts in this declaration are correct and I make this solumn declaration conscientiously
believing the same to be true and by virtue of Oaths and Declarations Act 1957.
Declared at
Before me
day month
Your signature
Authorised person’s full name and occupation/ authority
Authorised person’s signature
Damaged (if damaged please return
certicate to this ofce with the application)
(your full name and occupation) (place where you live)