Boards and Comittees Register Application Form

Personal details

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First name

Middle name

Family name

Gender

FemaleMale

Date of birth
(dd/mm/yyyy)

Day    Month    Year   

Home address

State  NSWACTNTQldSAVicWA    Postcode 

Phone number

Fax number

E-mail address

School, business or other address

State  NSWACTNTQldSAVicWA    Postcode 

Phone number

Fax number

E-mail address

Do you identify as a member of one or more of the following groups:

Education and employment

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Tell us about your education (school, TAFE, university, training or workshops, etc.)

Are you currently studying? Please give details.

Are you currently working? Please give details.

Please give details of past paid or unpaid work or work experience.

Are you a member of any organisations related to your work or study?
If so, please list them.

Are you a member of any other organisations? If so, please list them.

Interests and experience

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What are your special areas of interest?

What life experiences, strengths or skills do you think you can contribute?

Have you been on boards/committees for government or other bodies before?
Please give details.

Have you received awards or prizes or had any other recognition of special
things you have done? Please give details.

Interests and experience (select all that apply)

Referees

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Please give the names of two people who can tell us more about you.

Referee 1

Full Name

Address

State  NSWACTNTQldSAVicWA    Postcode 

Phone number

Referee 2

Full Name

Address

State  NSWACTNTQldSAVicWA    Postcode 

Phone number

If you are under 18 you must have discussed your application with a parent or guardian before you submit it.