Constitution of
Joombarn-buru Charitable Trustee Company Limited
SCHEDULE 1
APPLICATION TO BE NOMINATED AS A DIRECTOR
(To be completed by prospective director candidates)
APPLICANT TYPE
Please select one:
a JBAC representative
a Joombarn-buru Native Title Holders / JBAC member
an indenpendent director
APPLICANT DETAILS
Full Legal Name
Preferred Name
Residential Address
Postal Address if different
Contact Number
Email Address
example@example.com
Date of Birth
/
Day
/
Month
Year
Date
Current Occupation
PROFESSIONAL QUALIFICATIONS AND EXPERIENCE
Please list relevant professional qualifications memberships and directorship experience:
FIT AND PROPER DECLARATION
Have you ever been convicted of a criminal offence (excluding spent convictions)?
Yes
No
Are you currently or have you ever been bankrupt or subject to insolvency proceedings?
Yes
No
Have you ever been disqualified from managing corporations(by ASIC or any court)?
Yes
No
Have you ever been subject to disciplinary action by a professional, licensing, or regulatory body?
Yes
No
Are you mentally and physically capable of carrying out the duties of a director?
Yes
No
CONFLICTS OF INTEREST
Please select one:
I declare that I do not have any actual or potential conflicts of interest.
I disclose the following actual or potential conflicts of interest:
I disclose the following actual or potential conflicts of interest:
CONSENTS
I consent to being nominated as a director of the Company.
I declare that I am a fit and proper person to hold the position of director.
I consent to the Company conducting background, reference, and regulatory checks (including ASIC, police and bankruptcy checks) to verify the information provided in this application.
I confirm the information in this application is true and correct to the best of my knowledge and belief.
SIGNATURE
Name print
Signature
Date
/
Day
/
Month
Year
Date
ATTACHMENTS CHECKLIST
Résumé / CV
National Police Certificate (or consent to obtain one)
Copy of identification (e.g. driver’s licence or passport)
Additional disclosures (if applicable)
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