Goulburn Valley Health Community Advisory Group: Nomination Forma

Goulburn Valley Health
Community Advisory Group
Nomination form

Closing date: 18 September 2015

To assist us in timely selection, please ensure your nomination is submitted by the closing date to:

Goulburn Valley Health Community Advisory Group
Department of Health and Human Services
Capital Projects and Service Planning
GPO Box 4057
MELBOURNE VIC 3001

Alternatively, applications may be submitted by email to:

Nominationdetails

Surname:
Given name(s):
Home address:
Email address:
Home phone:
Work phone:
Mobile:
Occupation:

The Victorian Government is committed to ensuring that government boards and committees reflect the composition of the Victorian community. This includes appropriate representation of women, regional Victorians, Aboriginal people, young Victorians, Victoria’s culturally diverse community and Victorians with disability.

Are you an Aboriginal and/or Torres Strait Islander person?

Please mark with an ‘X’ as appropriate.For persons of both Aboriginal and Torres Strait Islander origin mark both ‘Yes’ boxes.

Are you Aboriginal? / Yes: / No: / Don’t know:
Are you Torres Strait Islander? / Yes: / No: / Don’t know:

Are you a person with a disability?

Yes: / No:

Note:Please attach no more than a 1–2 page resume.

Successful nominees must be able to attend regular meetings of the Community Advisory Group and will be required to declare any known conflicts of interest or agree to declare any conflicts as they arise during their term.

I hereby submit my nomination and declare all information I have provided is true and correct.

Signature of nominee:______Date: ______

Role

The Community Advisory Group will work in partnership with Goulburn Valley Health and will provide leadership by encouraging the community to participate during the planning stages of the redevelopment.It will advise Goulburn Valley Health and the department about community issues and concerns as they relate to the redevelopment and will provide a ‘bridge’ to the wider community.

What knowledge and experience would you bring to this group?

Please note your relevant past work/personal experience, community involvement, club/group membership, qualifications, and so on.

Is there further information you would like to add that would help in the assessment of your nomination?

Please note that additional pages can be attached if the space above is insufficient.

Your information is being sought for the sole purpose of developing a Community Advisory Group for the Goulburn Valley Health Redevelopment.Information gathered will be stored securely by the Department of Health and Human Services and will not be disclosed to anyone else without your consent.Contact details will only be used to inform you of upcoming meetings, times and locations and to forward pertinent information.

To receive this publication in an accessible format, email
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.© State of Victoria, Department of Health and Human ServicesSeptember 2015. Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people. Indigenous is retained when it is part of the title of a report, program or quotation.
Available at

Goulburn Valley Health Community Advisory Group:Nomination form1