PRELIMINARY ASSESSMENT QUESTIONNAIRE
PERSONAL DETAILS

CONTACT DETAILS
FAMILY DETAILS
FirstName:  
LastName:
MiddleInitial:
DateOfBirth (day/month/year):
Age:
ChooseGender:
Religion:
MainCitizenship/Nationality:
OtherCitizenships?
HomeAddressInHomeCountry:
PostCode:
Phone: 
Mobile:
Your address if you are in New Zealand now:
PostCode:
Phone: 
Mobile:
EmailAddress:
AlternateEmailAddress (if any):
If you are not living at your home address (home country), and if you are not in New Zealand, what is your current residential 
      address?
NumberOfChildren:
Male: 
Female: 
Ages: 
Citizenship/Nationality(s):
EDUCATION
Education:  State any and all qualifications finished (Courses, or Certificates, or Diplomas, or Degrees, or Masters)
Name of Completed Course/Degree/Certificate
Name of School/College and Address
Date Started
(month/year)
DateCompleted
(month/year)
PRESENT EMPLOYMENT
Occupation:
DateStarted: 
Phones: 
CompanyName&Address:
YourMainTasks:
HowLongInPresentJob:
Do you hold an occupational license or registration?
If yes, what occupation:
Name of Issuing Authority:
Date Issued:
Are you self-employed?
If yes, name on business registration papers:
Nature of Business:
Number of Employees:
PAST EMPLOYMENT (add pages if necessary)
Employment details since leaving school:
(Include only those for which you can obtain certificates of employment when asked for.):
From/To
(month/year)
Name and Address of Employer
Type Of Business
Title/Position
ReasonForLeaving
LANGUAGE DETAILS
Do you speak English?
Have you taken the IELTS exam?
If Yes:
Date exam was taken:
Your score in all areas:
Reading:
Writing:
Speaking:
Listening:
Overall Band Score:
PASSPORT DETAILS
Passport Number:
Place Of Issue:
DateIssued:
NZ Visa Expiry Date:
If you have been in countries apart from your country of citizenship in the past 10 years, please list them here and the dates you were there:
If you are now in New Zealand, what visa type are you holding? 
(visa types link  http://www.getnzvisa.com/Services.html)
If you had previously applied for a New Zealand visa, please state what visa, when, and outcome(s)?:
SPOUSAL/PARTNER/FIANCÉ DETAILS
GivenFirstName/s:
LastName:
MiddleName:
DateOfBirth (day/month/year):
Age:
ChooseGender:
CountryOfBirth:
Town/CityOfBirth:
Religion:
Citizenship/Nationality:
Current residential address if different from yours:
EmailAddress/es:
Does your spouse/partner/fiancé have any children of his/her own (not to you)?
If Yes, how many?:
 Age range:
If your spouse/partner/fiancé have been in countries apart from your country of citizenship in the past 10 years, please list
      them here and the dates he/she was there:
Has your spouse/partner/fiancé previously applied for a New Zealand visa?
If Yes, please state what visa, when, and outcome(s) or result?
Has your spouse/partner/fiancé previously applied for a visa to any other country apart from New Zealand?
If Yes, please state what visa, when, and outcome(s) or result?
If he/she is now in New Zealand, what type of visa is he/she holding?
Date current NZ visa expires:
Education of your spouse/partner: Write below the name of all qualifications finished (Courses, or Certificates, Diplomas, Degrees, or Masterals) 
Name of Completed Course/Degree/Certificate
Name of School/College and Address
Date Started
(month/year)
DateCompleted
(month/year)
Employment details of your spouse/partner since leaving school including current employment: (Include only those for which
      you can obtain certificates of employment when asked for at a later date). Add extra page as necessary.
From/To
(month/year)
Name and Address of Employer
Type Of Business
Title/Position
ReasonForLeaving
Does your spouse/partner speak English?
     Has your partner/spouse taken the IELTS exam?
If Yes:
     Date exam was taken:
     His/Her score in all areas:
Reading:
Writing:
Speaking:
Listening:
Overall Band Score:
Spousal/Partner Passport Number:
Place Of Issue:
DateIssued:
ExpirationDate:
OTHER DETAILS
How did you find out about this agency? 
If "Other", specify:
Describe any health problems that you or any additional applicant coming with you, have now, or have had in the past, if any:
Have you or any additional applicant coming with you, ever been convicted, imprisoned, or have any criminal case?
If so, please describe briefly:
Have you or any additional applicant coming with you been involved in terrorist activities?
Do you intend to start or acquire a business in New Zealand?
If yes, how much financing are you willing to commit to the business? 
US$:
NZ$:
Declaration (Please Read Carefully):
I declare that all the information provided in this application is true and correct. I understand that if I make any false statements, provide any false or misleading information, or omit to provide any relevant information, that I may be committing an offense and be liable to prosecution. I understand that this pre-assessment questionnaire is solely for the use of Asian And Philippine Immigration Assistance (NZ) Ltd. I further understand that all information provided shall be kept in confidence in accordance with the Privacy Act 1993.
Agree (Choose “yes” to agree): 
Submit Date:
Print Name:
Signature (Only if completed in ink):

Asian And Philippine Immigration Assistance NZ Ltd.  2/9 Phoenix Place, Papatoetoe, Manukau City,  Auckland, New Zealand 
 Tel +64 9 278 8767  Email [email protected]
Website Designed by Eugene Zita for Asian And Philippine Immigration Assistance NZ Ltd. Copyright © 2010  All Rights Reserved    
Valid Until:
Instructions: Fill out this form completely with true and correct information. All fields must be filled out. You must answer "NA" (Not Applicable) if a question does not apply to your situation.
If work or offer of work is in NZ, state your wage/salary per hour:
Number of hours work per week based on Employment Contract:
Other English test(s) taken for visa purposes in last 2 years and respective score:
Present Employment  of your spouse/partner:
Occupation:
DateStarted: 
Phones: 
CompanyName&Address:
MainTasks:
HowLongInPresentJob:
Does she/he hold an occupational license or registration?
If yes, what occupation:
Name of Issuing Authority:
Date Issued:
Self-employed?
If yes, name on business registration papers:
Nature of Business:
Number of Employees:
Number of hours work per week based on Employment Contract:
CountryOfBirth:
Town/CityOfBirth:
If work or offer of work is in NZ, state current wage/salary per hour:
If interested in Work or Residence Visa, what is your current salary or wage?: