visitor details form
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8/13/2019 Visitor Details Form
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VISITOR DETAILS FORM
Please print clearly. Please complete the declaration at the endby signing in the presence of a witness.
This Form and Declaration is to be completed in full by all visitors to The New Zealand Institute for Plant and FoodResearch Limited (Plant & Food Research or PFR)before arriving at the Institute.
Full Name of Visitor:
PFR Host/Supervisor: PFR Site:
Contact details
Address while at Plant& Food*Phone no. while atPlant & Food*Your Home/Residential Address
Your home/usualPhone no.
Nationality
Are you a Visiting researcher / post grad student / student intern / other (please specify)(Deleteas appropriate) Name and Address ofEmployer/University
Name of Line Manager/ University supervisor:If you are a student,what course are youundertaking* If you do not know these details in advance, please email details to the Visitor Administrator[[email protected]] after you arrive.
Some legal matters
Have you ever been charged or convicted ofany criminal offence (apart from parkingoffences), excluding any criminal offencesconcealed under the Criminal Records (CleanSlate) Act or equivalent?
Yes or No If yes, please specify
If you are from overseas, on what grounds areyou legally entitled to work in New Zealand?
Work Permit / Student Visa / NZ Residency / NZ Citizen(Delete as appropriateand attach a copy . Information can beobtained at http://www.immigration.govt.nz/ )
http://www.immigration.govt.nz/http://www.immigration.govt.nz/http://www.immigration.govt.nz/http://www.immigration.govt.nz/ -
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Are you intending to bring any biologicalmaterial with you for research purposes?
Yes or NoIf yes, please specify, and check with your host/supervisor toensure that the laboratory you will working in is approved forresearch on this material. If you are bringing this material fromoverseas, you must obtain permits from MAF Biosecurity(http://www.biosecurity.govt.nz/enter )
Health
Do you have any injury, medical condition, disability orillness (past or current) that may cause you any difficultiesor be aggravated by any activity you will be required toundertake as a visitor? e.g. Gradual Process Injury(previously OOS), hearing loss, joint or limb problems,dermatitis/skin problems, fits or epilepsy, allergies, asthma,eyesight problems, sensitivity to chemicals, backproblems.
Yes or No. If yes, please give details
Do you have any difficulty with wearing personal protectionequipment including goggles/glasses, safety shoes,laboratory coats, hearing protection, gloves etc.
Yes or No. If yes, please give details
Next of Kin / Emergency Contact details
Name of next of kin oremergency contactRelationship to mePhysical Address
PhoneEmailName of alternativeemergency contactRelationship to mePhysical Address
PhoneEmail
Name of Medicalinsurer & policynumber (if fromoverseas)Physical Address
PhoneEmailEmergency medicalcontact (optional)
Physical Address
Phone
http://www.biosecurity.govt.nz/enterhttp://www.biosecurity.govt.nz/enterhttp://www.biosecurity.govt.nz/enterhttp://www.biosecurity.govt.nz/enter -
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Email
DECLARATION
I (full name) declare that to the best of my knowledge, theanswers to the questions in this form and other information supplied are correct. I understand that if any false ordeliberately misleading information is given, or any material fact suppressed, I may not be accepted as a visitor to Plant &Food Research.
SIGNED: DATE:
WITNESS SIGNATURE:
Witness Name:
Witness Address:
Please send completed Form to Visitor Administrator, Human Resources, Plant & Food Research, Private Bag 92 169, Auckland 1142, New Zealand. Tel: +64-9-925 7063, Fax: +64-9-925 7003,Email: [email protected] from overseas, remember to attach a copy of your Work Permit, Student Visa, NZ Residency, or NZ Passport