Checklist for New Managers Certificate

Application form (Includes police supplement form)

Prescribed fee of $316.25

One reference from your current place of employment – stating dates of employment and duties. All references must be on letterhead, signed and dated.

One reference from a previous New Zealand employer – stating dates of employment and duties or a character reference. All references must be on letterhead, signed and dated.

A copy of your Licence Controller Qualification and a copy of the LCQ bridging test if LCQ issued under the Sale of Liquor Act 1989.

Copy of your Work Visa and Passport (only required if you are an overseas resident)The Managers certificate is only valid with a current Work Visa.

Please note managers certificates can only be issued to those with

• Current employment in a licensed premises• Six months experience in a licenced premises in New Zealand (if you do not have 6

months experience you may be put on hold until you do)• A valid work permit for New Zealand

Your application will not be formally accepted or processed until all information is lodged.

Waitaki District Council20 Thames StreetPrivate Bag 50058Oamaru 9444

Phone: (03) 433 0300Fax: (03) 433 0358Email: regulatory@waitaki.govt.nz

Application for Managers Certificate Checklist

For further information please contact For further information please contact

Copy of your Manager’s Certificate (only required if you previously held a Managers Certificate that has expired or was issued from another territorial authority).

All forms are signed by applicant

Updated: Jan 2017Updated: Jan 2017

Details of applicant

Full legal name __________________________________________________________

Aliases (maiden name) ____________________________________________________

Sex ___________ Occupation ______________________________________________

Date and place of birth ____________________________________________________

Mobile number ( ___ ) ________________ Daytime number ( ___ ) ________________

Email __________________________________________________________________

Residential address ______________________________________________________

Postal address __________________________________________________________

Criminal convictions [state all criminal convictions including traffic but not parking other than offences to which the Criminal Records (Clean Slate) Act 2004 applies)]

_______________________________________________________________________

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Has the applicant had any experience (in particular recent experience) in controlling any premises or conveyance in respect of which a licence was in force?

Yes No

If Yes, what are the details and dates of that experience (in particular recent experience) in controlling any premises or conveyance in respect of which a licence was in force?

Has the applicant had any relevant training, in particular, recent training?

Yes No

If Yes, what are the details of that training and on what dates was it taken?

_______________________________________________________________________

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Application for Managers Certificate - Form 17

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To the Secretary District Licensing Committee Waitaki District Council Section 219, Sale and Supply of Alcohol Act 2012

Updated: Jan 2017Updated: Jan 2017

Yes No

_____/_________/_______

Does the applicant intend at this time to be the manager of any particular licensed premises? Yes No

If “Yes”, what are the premise name, address, contact numbers?

_______________________________________________________________________

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If it is a club, what is the extent of the applicant’s involvement in management and activities?

_______________________________________________________________________

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Dated at (date and place) ______/_____/______ _______________________________ Location

Signature of applicant _____________________________________________________

The fee must be paid prior to, or at the time of, the application and proof of payment must be submitted with the application.

I confirm payment method as follows: Amount Paid $316.25

Date of Payment _____/_______/_____

If Yes, on what date was that qualification obtained?

Does the applicant hold the Licence Controller Qualification (or a prescribed qualification within the meaning of section 218 of the Sale and Supply of Alcohol Act 2012 - Bridging test)?

1. This application must be accommpanied by prescribed fee.2. If the applicant intends to be the manager of any particular licensed premises, the application must be filed with the Secretary of the District Licensing Committee that issued the licence.3. In all other cases, the application should be filed with the Secretary of the District Licensing Committee for the district in which the applicant is residing.

Note:

Updated: Jan 2017Updated: Jan 2017

NEW ZEALAND

POLICE REPORT

Updated: Jan 2017