Evaluation

DETAILS FOR NEW ZEALAND IMMIGRATION ASSESSMENT

Family Name :	* *	First Name :	* *
Sex :	Male Female	Date of Birth :	*
Citizenship(s) :	* *	New Zealand contact’s name and address (if any) :

Address :		E-mail :	* *
Phone :		Fax numbers for communication :

QUALIFICATION(S) FROM 10 + 2
Name of Institute	Name of the Certificate / Diploma/Degree	Percentage / Division Obtained
*	*	*

WORK EXPERIENCE
Name of Employer and / or SELF EMPLOYMENT DETAILS	Period of Employment / Business From / To Date, Month & Year	Position Title	Country in which employer and or business has its registered office	Income Tax Payee
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No

English Language Ability
Do you have IELTS certificate not more than two years old?	Yes No
Band Score : *

Details of Other Family Members
Name and Age	Country of Residence

NAME OF CHILDREN (biological, adopted or step)	Date of Birth

MARITAMARITAL STATUS

Married Never Married Divorced Separated Widowed In Civil Union/de facto and/or same sex relationship.

Name of Partner	Date of Birth
**	*

PARTNER’S
Address :		E-mail :
Phone :		Fax numbers for communication :

PARTNER’S QUALIFICATION(S) FROM 10 + 2
Name of Institute	Name of the Certificate/Diploma/Degree	Percentage/Division Obtained
*	*	*

WORK EXPERIENCE
Name of Employer/and or self employment details	Period of Employment/Business From/To Date, Month & Year	Position Title	Country in which employer has its registered office	Income Tax Payee
				Yes No
				Yes No
				Yes No
				Yes No
				Yes No

English Language Ability
Do you have IELTS certificate not more than two years old?	Yes No
Band score : *

Details of Partner’s Other Family Members
Name and Age	Country of Residence

NAME OF CHILDREN (biological, adopted or step)	Date of Birth

ASSETS AND INVESTMENTS OWNED INDIVIDUALLY OR JOINTLY WITH PARTNER AND CHILDREN

Property / Land	Registered Value

Shares / Units / Debentures etc.	Market Value

Bank Accounts	Funds Available

Gold / Diamond / Jewellery	Registered Value

Insurance Policy(s)	Surrender Value

Is anyone included in the application : Convicted or under investigation of any offence committed in the last ten years. Deported or excluded or removed, asked to leave, refused entry, or refused a visa/permit to any country including New Zealand. Involved with terrorism or drug trade.	Yes No Yes No Yes No
If Yes, to any of the above please provide details: *
Is anyone included in the application suffering from medical condition?	Yes No
If yes, describe medical condition and its prognosis in detail. *