ACT Place Names Committee Nomination Form

ACT Place Names Committee

Expression of Interest

Nomination Form

Applications closeTuesday 27 June 2017

As part of your expression of interest, please complete this form outlining your suitability to be considered for appointment to the committee.

The Terms of Reference for the ACT Place Names Committee are provided here

The Public Place Names (Naming of public places) guidelines are available here.

Appointment to the committee is for a three year term commencing on 1 October 2017.

Confidentiality

All information provided in this form will be treated as confidential.

To obtain a hard copy of this form, please contact the ACT Place Names Officer on
(02) 6205 0057 or (02) 6205 5318 or email

FURTHER INFORMATION

SECRETARIAT SUPPORT

Secretariat support to the Committee is provided by the ACT Place Names Unit within the Office of the Surveyor General and Land Information; Environment, Planning and Sustainable Development Directorate.

CONTACT DETAILS

ACT Place Names

Office of the Surveyor-General and Land Information

Environment, Planning and Sustainable Development

GPO Box 158

Canberra ACT 2601

Phone: (02)6205 0057 or (02) 6205 5318

Email:

Expression of Interest for appointment to the ACT Place Names Committee

Nominee Details

Name: ______

Telephone(during business hours): ______

Email:______

Cultural background:

Are you a member of any of the following groups?

Aboriginal
Torres Strait Islander
Culturally and Linguistically Diverse Background
Other: please specify:

Are you nominating as a representative of a particular group or organisation?

Yes / No

If yes, which group or organisation:

This is an expression of interest and does not guarantee appointment to the
ACT Place Names Committee.

For further enquiries related to this nomination, please contact the ACT Place Names Officer on telephone: (02) 6205 0057;(02) 6205 5318 or email

Please provide a brief outline below of your suitability for appointment to the membership of the ACT Place Names Committee (approximately 500 words). You may wish to provide a copy of your current CV to supplement your expression of interest.

Nominee full name:

Please return this form by close of businessTuesday 27 June 2017

Either:

E-mail this document marked ‘ACT Place Names Committee – EOI’ to:

Print this document and submit by post to:

ACT Place Names

Office of the Surveyor-General and Land Information

Environment, Planning and Sustainable Development

GPO Box 158

Canberra ACT 2601

Print this document and deliver by hand during business hours 8:30am to 4:30pm Monday to Friday to:

ACT Place Names

Office of the Surveyor-General and Land Information

Environment, Planning and Sustainable Development

Ground Floor South
Dame Pattie Menzies House
16 Challis Street
Dickson ACT 2602