Section 14(4) of the Protected Objects Act 1975. Full name * This name will appear on the certificate Physical Address * Are you ordinarily resident in New Zealand? * Yes No Please provide details on the amount of time spent in New Zealand and frequency, and your usual place of residence * Have you ever been convicted of an offence against any provision of the Protected Objects (previously known as the Antiquities Act) or of the Historic Places Act? * Yes No Conviction Details * Please provide relevant details of the conviction Where will taonga tūturu acquired under this certificate usually be held? * Contact Details Phone Number (work/home) * Fax Email * Postal Address * Declaration by Applicant I declare to the best of my knowledge that the contents of this application are true and correct. I undertake to comply with all of the following conditions: I shall only transfer taonga tūturu in my collection to: another registered collector, a public museum, or an auctioneer or secondhand dealer licensed to trade in taonga tūturu (Note: if the transfer involves a gift or bequest to a relative, the relative does not need to be registered as a collector). I shall make my collection available for examination by any person so authorised by the Chief Executive of the Ministry for Culture and Heritage. I shall notify the Chief Executive of the Minist ry for Culture and Heritage of any change in my collection within 14 days of the change I shall notify the Chief Executive, Ministry for Culture and Heritage within 14 days of any change in the location of the collection. Signature * By entering your name here you are legally Signing your name Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20212022202320242025 Updated on 19th March 2021