Regional Advisory Committee Application Form

Office of Environment and Heritage

Regional advisory committee application form

From 1 September 2018, the eight committees across the state will align with the eight NPWS Operations Branches – see the administrative region covered byeachcommittee on the map of NSW branches at .

I wish to be considered for appointment to the following regional advisory committee (RAC):

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☐ Blue Mountains RAC

☐ Hunter Central Coast RAC

☐ Greater Sydney RAC

☐ North Coast RAC

☐ Northern Inland RAC

☐ South Coast RAC

☐ Southern Ranges RAC

☐ WestRAC

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Applicant details

Title: ______First name:______Middle name: ______

Last name:______Post nominals: ______Dateof birth: ______

Home address: ______

Postal address: ______

Town or suburb: ______State: ______Postcode: ______

Telephone: ______Mobile: ______

Emailaddress: ______

Diversity statistics

This information will be used to measure diversity in appointments. Members of the community, including women, Aboriginal and Torres Strait Islander people, people of culturally diverse backgrounds, people with a disability and young people (18–24), are encouraged to apply for positions on NSW boards and committees.

Gender: ______

Are you a person with a disability? Yes ☐ No☐

Are you an Aboriginal or Torres Strait Islander person? Yes ☐ No ☐

Do you have a culturally and linguistically diverse background? Yes ☐ No ☐

If yes, please provide details: ______

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Category of RAC Membership

I meet the following requirement(s) for membership on the committee (as listed in Schedule 8 of the National Parks and Wildlife Act 1974)and can support my claim in this application and my curriculum vitae. Please select one or more qualifications that apply to you.

☐ Aboriginal person

☐ Joint nominee of the Nature Conservation Council of NSW/National Parks Association of NSW

☐ Expertise and experience in local government

☐ Expertise and experience in community involvement in conservation

☐ Expertise in Aboriginal cultural heritage

☐ Scientific qualifications in conservation biology, wildlife management or related disciplines

☐ Expertise and experience in rural or regional issues

☐ Expertise and experience in agriculture and rural issues, being a person nominated by the NSW Farmers’ Association

☐ Expertise and experience in ecotourism or ecologically sustainable visitor or tourist use, enjoyment and appreciation of reserves

☐ Expertise and experience in environmental education and community involvement in environmental education

☐ Expertise in non-Aboriginal cultural heritage conservation.

Applicant’s qualifications, expertise and experience

List your qualifications, expertise and experience in support of your application. (If nominating in more than one of the above eleven categories, please list supporting evidence for each category.)Add additional pages if required.

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Are you a currentmember of any other government boards and committees,including RACs? Yes ☐ No ☐

If yes, please list and advise term of appointments.

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Are you a public servant? Yes ☐ No ☐If yes, which agency and what role?

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Are you listed on the NSW Register of Third-Party Lobbyists? Yes ☐ No ☐

If yes, please provide details below.

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For review purposes, it would be appreciated if you would provide detail of how you learnt of this opportunity to nominate for membership of a RAC (e.g. NSW Government Boards and Committees website, Office of Environment and Heritage (OEH) website, direct email, advertisement andin whichpublication, colleague orother source).

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Authorisation and signature

I certify that my answers are true and complete to the best of my knowledge.

I approve the NSW Government undertaking probity checks, as deemed appropriate for applications to this committee.

I acknowledge that if I am approved for appointment to the committee, that I will be required to declare pecuniary/non-pecuniary interests.

Signature______Date: ______

Closing date and lodgement

When you have completed this form, please save it and then email the form and your curriculum vitae toor post to RACStakeholder Liaison Officer, NSW National Parks and Wildlife Service, PO Box 1967, Hurstville NSW 2220by Tuesday1 May 2018.

Enquiries

For further information, email

Privacy Statement

The Information submitted on this form, including personal details, will be stored in the OEH records system. OEH must comply with the Privacy and Personal Information Protection Act 1998 (NSW), which regulates the collection, storage, quality, use and disclosure of personal information. For details, see ‘OEH and your privacy’ at . By submitting this form, you consent to the collection and use of your personal information in accordance with this. I also understand that my personal information may be disclosed to other NSW Government departments and agencies, including the Department of Premier and Cabinet, and/or Ministers for the purposes of the appointment process.

Office of Environment and Heritage, 59 Goulburn Street, Sydney South NSW 2000. Phone: 131 555 (environment information and publications requests); email: ; Website: OEH 2018/0225; April 2018

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