ACH Committee EOI form

Expression of Interest

Nominations are sought from suitably qualified individuals to become members of the Aboriginal Cultural Heritage Committee (ACHC).
Nominee Details
Title*
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Are you of

Aboriginal descentTorres Strait Islander descent
What is your country of birth?*
Is a language other than English spoken at home?
Do you have any medical conditions, injuries, or disabilities that may impact on your ability to undertake the position? *

YesNo
If 'Yes', please give details. *Please note, disclosure of an illness, injury or disability will not exclude an applicant.
Do you have any current convictions for any offences from any court, or are you currently the subject of any charge pending before any court? You do not need to give details for any conviction which you have had declared spent (West Australian Spent Convictions Act 1988). A criminal record does not necessarily disqualify an applicant.*

YesNo
If 'Yes', please give details.
Are you currently employed in the West Australian Public Sector?*

YesNo
If 'Yes', please give details
Please note: Commonwealth, State and Local Government Employees are not eligible to receive sitting fees.
Describe your knowledge of and experience in matters relating to Aboriginal cultural heritage as relevant to the work of the ACHC:*
The Minister may take into account any matter relevant to the person’s ability to carry out functions as an ACHC member, including knowledge, skills, experience or qualifications. Please indicate any knowledge, skills, experience or qualifications relevant to the role of the ACHC.
Aboriginal lore and culture check box

AnthropologyArchaeologyEngineeringEthnographyGovernanceHistoryLand managementLawNatural resource managementUrban and regional planning
Current employer and position:*
Describe your work history as it relates to knowledge, skills, experience or qualifications in the areas relevant to the role of the ACHC:
Describe any other previous board experience, including your position and a brief description of your role:*
Please provide details of any other boards / professional bodies you are currently a member of, including your position and a brief description of your role:*
Describe the skills and experience you would bring as a board member of the ACHC:*
Describe your voluntary involvement relevant to board position:
Detail your qualifications and training relevant to the board position:
Attach your current CV

Cancelof
Please provide the contact details for two current referees that can be contacted for verification of the claims made in this application.
Referee 1*

First NameLast Name
Organisation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Referee 2*

First NameLast Name
Organisation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
I confirm that all the information contained within this application is correct.
Nominee signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Expression of Interest