Water Services Committee

Water Services Committee

NOMINATION FORM 2017

We the undersigned nominate:

Name ……………………………………………………………………………………….

Address ……………………………………………………

……………………………………………………

Phone ………………………………………………………………………………………..

Email ………………………………………………………………………………………..

Please see page 2 of this form for information on eligibility.

As eligible for membership of the:

To be considered, this nomination form must be received at Goulburn-Murray Water by close of business Friday 19 May 2017 by:

Nominee eligibility

Please tick the boxes to indicate you meet the eligibility criteria for appointment -

o  I am a Goulburn-Murray Water customer or,

o  I am not a customer, but I am a resident in the relevant designated operational area of a Committee.

And, I am not / I have not been:

o  an undischarged bankrupt; or

o  insane; or

o  found guilty of an offence under the Water Act 1989; or

o  convicted of any indictable offence within the last 5 years; or

o  more than 12 months in arrears in the payment of water charges to Goulburn-Murray Water (without having made an arrangement to pay the arrears which is acceptable to Goulburn-Murray Water).

DECLARATION OF CUSTOMER COMMITTEE MEMBER NOMINEE

I have been nominated for and am eligible for appointment to the

Central Goulburn Water Services Committee

and I hereby confirm that I accept such nomination and that I have read, understood and undertake to comply with the Goulburn-Murray Water Water Services Committee Operating Rules (which is available at www.gmwater.com.au)

Signed

Print Name

Date

*This declaration is to be completed and forwarded with your nomination form and your 100 word profile (examples of current committee member profiles are available under each Water Services Committee members page at www.g-mwater.com.au/wsc)