Form of notice acceptable:

Digital format (eg, excel spreadsheet or other electronically readable data)

Can be fillable PDF

How form to be completed:

By vessel master only

How the notice to be given:

Between 168 and 192 hours’ notice before the ship arrives in New Zealand, or, if that is not practicable, when the ship departs for New Zealand from a port or place outside New Zealand

Requirements for All Ships Arriving in New Zealand

1. Vessel name:

Free text

2. Country of registration (flag state):

Free text

3. International Maritime Organisation (IMO) number or registration number:

Free text

4. Port of First Arrival:

Free text

5. Date and time of arrival in New Zealand territorial waters (12 nautical mile boundary):

Date time

6. Last overseas port or place visited before arrival in NZ territorial waters:

Free text

7. Date and time of departure from last port:

Date time

8. Name of master:

Free text

9. Number of crew:

Number

10. Number of passengers:

Number

Additional Requirements for Category 1 Ships as defined in clause 9(1) of the Order

11. I confirm that all crew and passengers arriving in New Zealand on board this vessel are aware of their requirement to undergo compulsory COVID-19 testing if they wish to disembark this vessel in New Zealand.

Yes/No

12. I confirm that all crew and passengers are aware of their self-isolation requirements should a positive COVID-19 case be detected on board this vessel.

Yes/No

13. I understand my requirement to notify a Medical Officer of Health of the results of any compulsory COVID-19 testing on board this vessel, and that failing to do so is a high-risk infringement offence.

Yes/No

14. Specify the number of people disembarking this vessel in New Zealand:

Number

Additional Requirements for Category 2 ships as defined in clause 9(2) of the Order

15. I confirm that all persons on board are aware of their vaccination and self-isolation requirements.

Yes/No

16. I confirm that there are systems and processes in place that enable me to check whether persons on board have complied with the vaccination requirements as specified by Director-General Notice.

Yes/No

17. Upon arrival in New Zealand, when requested to do so, I will provide satisfactory evidence that every person has complied with vaccination requirements, satisfactory evidence being a record with:

1. the person’s name showing they received 1 or more COVID-19 vaccines; and
2. the name of the COVID-19 vaccine(s) they have received; and
3. the name of the agency that administered the COVID-19 vaccine(s); and
4. the associated time(s) and place(s).

Yes/No

18. For cruise vessels only: If a third party verification service was used to confirm vaccination status of persons on board, please specify the service used and the results:

Free text

19. Please provide the following details for all persons on board:

1. Full name
2. Date of birth
3. Nationality/citizenship/visa status (indicating their right to enter New Zealand)
4. Passport number
5. Vaccination status (vaccinated, unvaccinated, exempt, excused)

May be in a separate document

20. I confirm that the information in this form is true and correct

a. Signature

Free text

b. Name

Free text

c. Date

Date