Expression of Interest –Dairy Food Safety Victoria Board

Name:

Last Name / First Name / Title

Preferred Address for Correspondence

Address / Suburb/City / Postcode

Contact Numbers

Business Hours / After Hours / Other
Tel:
Fax: / Tel:
Fax: / Mobile:
Email

Academic Qualifications

Qualification / Institution / Year Graduated

Current Occupation and Employer (if relevant)

Title / Employer / Period

Knowledge, Experience and Skills in areas covered by Dairy Food Safety Victoria activities

Provide summary details of your background that demonstrates experience in one or more of the areas listed in the Background Briefing. This can be supplemented by an attached resume.

Personal Attributes

Please list personal abilities and competencies you have which you believe are relevant to holding a Dairy Food Safety Victoria Board position. Please refer to the Background Briefing paper.

Relevant Committees and Board Experience

Please list your current or previous memberships and experience in relevant business or community organisations and boards.

Supporting Rationale

Why would you like to be a member of the Dairy Food Safety Victoria Board? What particular attributes or value add do you believe you bring?

References

Please list down 3 referees, their relevance and contact details.

Please Note:

A person is not eligible for appointment if they are of unsound mind or a person whose person or estate is liable to be dealt with in any way under the law relating to mental health, or is bankrupt, or would be disqualified from obtaining an industry license under the fit and proper person provisions of the Dairy Act 2000.

The information provided by you will be conveyed to the Department of Economic Development, Jobs, Transport and Resources and to various persons for the purposes of identifying possible appointments to the Dairy Food Safety Victoria Board. The Department of Economic Development, Jobs, Transport and Resourcesand its advisory consultant may approach any person or body for the purposes of verifying claims made in this application.

Having read the above, I hereby declare that I am eligible to be a director under the Corporations Law, am eligible to be a member of the Dairy Food Safety Victoria Board and confirm that the information contained in this form is true and complete.
Signature*: Date:

*This form will be accepted by email, not requiring a physical signature. However, before a formal interview, the form will need to signed as an original.

Completed Expression of Interest Form and Curriculum Vitaeshould be forwarded by 9am Monday 29 June 2015 to Kathryn Harper,theconsultantassisting theDairy Food Safety Victoria Selection Committee, via email, to oting“Dairy Food Safety Victoria Expression of Interest” in subject line. Or by mail to:

Kathryn Harper

Director

Horton International

Level 9, 52 Collins Street

Melbourne, Vic, 3000

Please direct any questions regarding the process to Kathryn on (03) 9650 2555.