Attachment A – Application Form
PERSONAL DETAILSTitle:Ms Mr Dr Prof.
Surname: / First Name: / Initial
Date of Birth: / Gender: female male
Postal address: / State: / P/code:
Email:
Phone (W): / Phone (H):
Phone (M): / Fax:
Occupation:
Current employer:
Position (if relevant):
Have you applied or participated in any of the Industry Partnerships Programme’s capacity bulding initiatives before?
Young Rural Leaders’ Course Young People’s Rural Development Awards
Young People’s Corporate Governance Scholarships Study Awards
Young People’s Export Market Development Training Course International Observers
ELIGIBILITY
Are you currently involved in agriculture, fisheries or forestry?
YES NO(ineligible)
Please describe your involvement (10 words or less):
Are you aged 18-35 years? YES NO(ineligible)
Are you an Australian Citizen? YES NO(ineligible)
Are you an Indigenous Australian? YES NO
Are you a Primary Producer? YES NO
Do you have access to computer equipment and the internet?
YES NO (ineligible)
Please provide details:
Are you able to commit approximately 10 hours per week to the management of the YARN website for the remainder of the 2006-2007 financial year?
YES NO (ineligible)
Are you directly employed by a:
-Government agency (either Australian or State);
-Research and Development Corporation; OR
-Cooperative Research Centre (CRC)?
NO YES (ineligible) / Are you a full-time student?
YES (ineligible)
NO
REFEREE DETAILS
Please provide the contact details of two nominated referees.
Your referees must be in a position to comment about your performance against the Selection Criteria.
Name:
Position:
Employer:
Relationship to applicant:
Phone No:
Email: / Name:
Position:
Employer:
Relationship to applicant:
Phone No:
Email:
DAFF may contact the referees of short listed applicants.
DISCLAIMER
The Australian Government Department of Agriculture, Fisheries and Forestry (DAFF) collects personal and corporate information for the purpose of carrying out its functions and performing its duties under the Young People in Rural Industries Program. DAFF may use the information to advise you of opportunities, seminars, conferences, trade fairs and other related activities. DAFF may also use the information for its marketing or promotional purposes and may disclose it to contracted service providers and agencies that assist DAFF to perform its role and to other organisations that are considered to have an investment in a related purpose. Information may also be disclosed in accordance with the Information Privacy Principles in the Privacy Act 1988.
Please contact us if you require additional information about this statement.
CERTIFY
I hereby declare that:
- All information in this Expression of Interest is correct; and
- I consent to my personal information being used in the administration and promotion of the Young People in Rural Industries Program.