Statutory Boards and Committees Application

If you have previously submitted an application and wish to update your details, or you are having problems submitting this application, please send an email to statutory_boards_committees@moh.govt.nz

Otherwise, please enter your details into the field in Section 1 below, then click the 'check' button.
If the response you receive is that a record already exists, please email your updated details to statutory_boards_committees@moh.govt.nz.

If you receive a 'no entry currently exists' then please complete the details from Section 2 to submit a new application.

Thank you.

1. Database Check - please enter your email address

E-mail:

2. Personal Details * denotes mandatory field

Title:

* First Name/s:

* Surname:

Organisation/Employer:

* Job Title:

Occupation/Specialist Area:

Other (please specify):

* Home Address:

* Home Telephone:

Home Facsimile:

Mobile Telephone:

Postal Address (if different):

Business Address:

Business Telephone:

Business Facsimile:

* E-mail:

* Citizenship:

Date of Birth (dd/mm/yyyy):

* Gender:

Female Male

Which ethnic group do you belong to? (mark the space or spaces that apply to you)

New Zealand European
Mäori
Samoan
Cook Island Mäori
Tongan
Niuean
Chinese
Indian
Other

Other (please specify):

Iwi (if Mäori):

Geographic Location:

North South

Disability (if applicable)

General Skills:

Academic/Policy
Education
Finance
General Management
Law
Medical (Clinical, Community, Disability, Mental Health, Nursing, Other)
Property
Social Services
Technical/Project Management
Government Board Experience
Private Board Experience
Voluntary Board Experience

Are you applying for a specific committee?

Yes No

If Yes, which committee are you applying for?
(tip: hold down Ctrl to select multiple)

Educational Qualifications

Institution	Year	Qualification







Career/Work Experience

Summary of Career Experience

Please include a summary of your relevant career experience. List the from the oldest to the most recent.

Employer Name	Period in Years (eg 1999 - present)	Positions Held and Major Experience

Government Board Member or Director Experience

Please list details of all current and any significant previous government appointments, board memberships or directorships. List the from the oldest to the most recent.

Organisation	Period in Years (eg 1999 - present)	Role

Private/Relevant Voluntary Organisation Service

Please list details of all current and any significant previous voluntary service positions held. List the from the oldest to the most recent.

Organisation	Period in Years (eg 1999 - present)	Role

What are the types of committees/bodies to which you could make the best contribution?

Please include a personal statement describing what attributes you would bring to the position (board/council/committee).

Referees

Name	Address	Phone

Curriculum Vitae

Please attach your C.V. here.

Conflicts of Interest

* Please state any financial, professional or personal conflicts of interest you may have if you are appointed as a member of a board or committee.
(Please state nil if otherwise)

* Candidates should divulge anything in their personal histories that should be brought to the attention of the Minister of Health. In particular they should divulge details of any criminal convictions or complaints upheld, or being investigated, by the Health and Disability Commissioner or any other relevant professional investigating body (please state nil if otherwise)

Privacy Statement

* The information provided in this form will be used to determine the applicant’s suitability for consideration for appointment to a statutory body. If you wish, the information you have provided will be kept electronically for consideration in respect of future vacancies on statutory bodies.

The agency that will collect and hold the information is:
Ministry of Health
133 Molesworth Street
PO Box 5013
WELLINGTON

You have the right of access to, and correction of, information about you that is stored on a database.

I wish to have the information provided on this form retained in a database for consideration of future vacancies on boards
I Do Not wish to have the information provided on this form retained in a database for consideration of future vacancies on boards

Authority and Declaration

I authorise the named referees and any registration authority holding information relevant to the consideration for my appointment to a statutory body to disclose that information to the Ministry of Health.

I have completed all sections of the application form and the information supplied in this application is correct. I understand that providing incorrect, incomplete or misleading information will render this application invalid and may result in the revocation of any appointment made in reliance of such information.