Please refer to the information for applicants document before you complete this form.

Applicant details

First name

Last name

Postal address

(include street address and postcode)

Business address

if applicable (include street address and postcode)

Contact number

Country or Mob you most identify with

Organisation

Please include any current employment and other relevant organisations or groups - this may membership based, volunteer based or other.

Other details

Which position on the committee are you applying to be considered for

Independent Country or cultural practice adviserIndustry representative (e.g. employed in a business listed on Supply Nation or the NSW Aboriginal Business Portal or by an Aboriginal Community Controlled Organisation (ACCO), etc.) Community group representative (e.g. involved in community at any level, membership is not a requirement)You can apply for more than one position, and we can discuss with you which would work best. You can also call us for more information if you are unsure

Are you requesting to be considered for the role of chair of the committee?

YesNo

Are you currently a member of other boards and/or committees?

YesNo

If yes, please list the boards and/or committees

Are you a public sector employee?

YesNoImportant: public sector employees should seek their manager's support for their nomination and provide contact information for their manager.

If yes, please provide the department name

Manager's contact details

Experience, knowledge and skills

Please outline your knowledge and experience for this role

Relevant areas include fresh water, salt water, fire, air and sky, land, culture, totemic animal or/or plan species, or any relevant area.

Other highly regarded experience includes land and/or cultural resource management, restoration ecology, threatened species management, ecological/cultural fire practices/management, invasive species management, community engagement/education, Aboriginal community-run projects, or any other relevant areas.

Do you have experience related to these areas?

YesNo

If yes, please provide details

(for example, which organisation does this relate to)

Please describe your experience in working with a group/team/committee in relation to caring for Country

This can include providing advice, being part of a group/team directly working on Country, being part of a committee/group within an Aboriginal Community Controlled Organisation or any other body.

Please describe your experience or capacity in providing advice and/or making decisions fairly in the best interests of all involved

Have you had this experience as a community member or within your workplace?

Supporting documents

Please provide a current resume/curriculum vitae

(if available, maximum 3 pages)

References

Please provide the details of 2 referees (referees will be contacted as part of the application process).

Referee 1

Full name

Relationship

Referee email

Referee phone

Role and organisation/community name

(where relevant)

Referee 2

Full name

Relationship

Referee email

Referee phone

Role and organisation/community name

(where relevant)

Diversity

The Department of Climate Change, Energy, the Environment and Water's aims to create thriving environments, communities and economies for the people of New South Wales. We strive to be a high-performing, world-class public service organisation that celebrates and reflects the full diversity of the community we serve and seeks to embed Aboriginal cultural awareness and knowledge throughout the department.

We welcome and encourage diverse applications from all people.

Your responses to the below questions will help to form a diverse and representative committee where there is opportunity to do so within merit selection principles.

What is your gender identity?

FemaleMaleNon-binaryPrefer not to answer

Are you a person with a disability?

YesNoPrefer not to answer

If yes, do you require any adjustments?

Other cultural or linguistic diversity

Tick if you do not wish to be considered for future technical review committees.

Disclaimer and signature

I certify that my answers are true and complete to the best of my knowledge.
I approve the NSW Government undertaking the following probity checks, as deemed appropriate for applications to this committee: ASIC Banned and Disqualified search, ASIC Enforceable Undertakings Register search, Australian Financial Security Authority National Personal Insolvency Index search, NSW Police Force National Police Check and Office of the Children's Guardian Working with Children Check.
I acknowledge that if I am approved for appointment or reappointment to the committee, that I will be required to declare pecuniary/non-pecuniary interests.

Signature

Date