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Please print clearly. Please complete the declaration at the end by 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 Food Research 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 at Plant & Food* Your Home/ Residential Address Your home/usual Phone no. Nationality Are you a Name and Address of Employer/University Name of Line Manager / University supervisor: If you are a student, what course are you undertaking * If you do not know these details in advance, please email details to the Visitor Administrator [visitor. administrator@plantandfood.co.nz] after you arrive. Visiting researcher / post grad student / student intern / other (please specify) (Delete as appropriate)

Some legal matters

Have you ever been charged or convicted of any criminal offence (apart from parking offences), excluding any criminal offences concealed under the Criminal Records (Clean Slate) Act or equivalent? If you are from overseas, on what grounds are you legally entitled to work in New Zealand? Yes or No If yes, please specify

Work Permit / Student Visa / NZ Residency / NZ Citizen (Delete as appropriate and attach a copy. Information can be obtained at http://www.immigration.govt.nz/ ) 1

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Are you intending to bring any biological material with you for research purposes?

Yes or No If yes, please specify, and check with your host/supervisor to ensure that the laboratory you will working in is approved for research on this material. If you are bringing this material from overseas, you must obtain permits from MAF Biosecurity (http://www.biosecurity.govt.nz/enter)

Do you have any injury, medical condition, disability or illness (past or current) that may cause you any difficulties or be aggravated by any activity you will be required to undertake 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, back problems. Do you have any difficulty with wearing personal protection equipment including goggles/glasses, safety shoes, laboratory coats, hearing protection, gloves etc. Yes or No. If yes, please give details

Yes or No. If yes, please give details

Next of Kin / Emergency Contact details

Name of next of kin or emergency contact Relationship to me Physical Address Phone Email Name of alternative emergency contact Relationship to me Physical Address Phone Email Name of Medical insurer & policy number (if from overseas) Physical Address Phone Email Emergency medical contact (optional) Physical Address Phone
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I (full name) declare that to the best of my knowledge, the answers to the questions in this form and other information supplied are correct. I understand that if any false or deliberately misleading information is given, or any material fact suppressed, I may not be accepted as a visitor to Plant & Food Research.



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: visitor.administrator@plantandfood.co.nz If from overseas, remember to attach a copy of your Work Permit, Student Visa, NZ Residency, or NZ Passport

V1 09/08 Visitor Details