Expression of Interest Regional Forum

*- indicates required field.
This form should be personally completed and signed by the applicant. The application, along with any other supporting documents you wish to supply may be emailed to regionalforum@es.govt.nz; mail it to Environment Southland, Private Bag 90116, Invercargill 9840; or drop it in to our offices at the corner of North Road and Price Street, Waikiwi, Invercargill.

The information we are requesting is being gathered to ensure the diversity of the regional forum, so that the forum reflects the region.

The closing date for applications is 5pm Friday 15 February 2019. Please attach any additional information to support your application.

NB: If you are nominating someone and completing this form on their behalf, the nominee needs to sign the form to indicate their acceptance of the nomination prior to it being lodged with us.

Personal Information

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Character References

Name two people (whose consent you have obtained) whom we can contact for references if required.

Referee 1

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Referee 2

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Declaration

I declare that the information I have supplied on this application form, and/or in my supporting documents, is true and correct.
I accept that should my application be successful, the above information will form part of my appointment to the Regional Forum and that falsification of information, or suppression of material facts on this form or on any other document, is grounds for termination of membership of the Regional Forum. I understand that if I am invited for an interview I may be required to provide additional personal information, and if I am offered an appointment to the Regional Forum, that information will form part of my application and as such must also be true and correct.
Privacy Act 1993
Your signature on this application form confirms your permission for a member of the selection panel to contact the referees you have listed on the application form. The referee’s reports will be kept confidential to the selection panel unless their disclosure is authorised by the referee.
In accordance with the Act we are unable to hold your application ‘longer than is required for the purposes for which the information may lawfully be used’ and, therefore, unsuccessful applications and supporting documents will be destroyed after three months.

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