The Privacy Officer
Department of Internal Affairs
P O Box 10-526
WELLINGTON
 
Dear Sir/Madam
 
FULL NAME: _______________________________________________________________

DATE OF BIRTH:  ___________________________________________________________

PLACE OF BIRTH:  __________________________________________________________

I am a NZ Citizen:        YES		 NO
 
Please provide me with any personal information that the Department of Internal Affairs 
holds about me.
 
By circling the service below, I have indicated what sort of personal information I would 
like to know about.
 	
  Passports					  Births, Deaths and Marriages
  Citizenship					  Gambling Compliance
  Archives New Zealand
  Other - Please specify ____________________________________________________
  
OR

•	Correct my_________________________________________________________
	(information that you believe to be incorrectly recorded)*

•	Your records show this as____________________________________________
	(how the incorrect information is currently recorded by the Department of Internal Affairs)*

•	Please correct this to ________________________________________________
	(what you believe is the correct information)*
 
(*Omit which does not apply)

In support of my belief that the information is incorrectly recorded I supply 
the following documents: 

(Please list the documents that verify that your information has been incorrectly recorded).
•

•

•

•

•
 
Please send the information to:	

Your name:____________________________________________________________________

Your address (must be a physical address and NOT a post office or box number if not in NZ):

____________________________________________________________________________

Your contact phone number (land-line): _____________________________________________

Your cellphone number: _________________________________________________________

Your email address: ____________________________________________________________

Yours sincerely	

		
 
(your signature)