We would like to inform you that the information contained in your application will be confidentially maintained in accordance with the principles of the Privacy Amendment (Private Sector) Act 2000 and the Privacy and Personal Information Protection Act 1998.

1. Yes I agree to the privacy statement*

1. Title* Mr Mrs Ms Miss Dr Other
2. First name*
3. Last name*

1. E-mail*
2. Phone*

   Digits only or add + for international numbers

1. Street*
2. Street Cont.
3. City, Town or Suburb*
4. Postcode or Zipcode*
5. Country*Please choose... AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BRAZIL BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE INTERNATIONAL OTHER Unknown
6. State, Region or Province*Please choose...

1. Gender Male Female Non-binary / Non-conforming Prefer not to say

1. LinkedIn URL

   (Please click on your profile and copy the URL from your profile page.)

1. Independence Criteria
   
   Section 216F(1) of the Local Government (General) Regulation 2021 (effective July 2024) specifies the independence requirements and are set out in 10 initial questions below:
   
   Are you a current councillor of any council in NSW?*

   1. Yes
   2. No
2. Were you a Bathurst Regional councillor during the 2016-2021 term?*

   1. Yes
   2. No
3. Were you a candidate at the 2021 council election of Bathurst Regional Council, or will you be a candidate in the 2024 council election of Bathurst Regional Council?*

   1. Yes
   2. No
4. Are you a non-voting representative of the Central NSW Joint Organisation?*

   1. Yes
   2. No
5. Have you been employed by Bathurst Regional Council in the previous 12 months*

   1. Yes
   2. No
6. Do you conduct audits of Bathurst Regional Council for the Audit Office of NSW?*

   1. Yes
   2. No
7. Do you have a close personal or business relationship with a councillor or a person who has a senior role in Bathurst Regional Council that may lead to an actual or perceived conflict of interest?*

   1. Yes
   2. No
8. Do you provide, or have you in the previous three years provided, material goods or services which directly affect matters considered by the Audit, Risk and Improvement Committee (eg consultancy, legal, internal audit or advisory services)?*

   1. Yes
   2. No
9. Are you (or do you have close family member who is) a shareholder, owner, officer or employee of a company that:
   
   a) the company has a business relationship with Bathurst Regional Council or a related entity (meaning an entity formed by Bathurst Regional Council or which the council participated in forming), and
   
   b) the business relationship comprises:
        i) a material business relationship, or
        ii) a contractual relationship, or
        ii) a direct financial interest, or
        iv) a material indirect financial interest, and c) the business relationship could reasonably be considered to be an actual or perceived conflict of interest? *

   1. Yes
   2. No
10. Do you act, or have previously acted, as an advocate for Bathurst Regional Council or a related entity, and the advocacy: i) relates to a material interest, and ii) could reasonably be considered to be an actual or perceived conflict of Interest. *

    1. Yes
    2. No
11. Application Form
    
    Are you expressing an interest in the role of independent member Note: There is currently one two year independent member role. *

    1. Independent Member
12. Please outline any formal qualifications you hold that would assist you in this role. *
13. Please outline any relevant professional knowledge and expertise you possess that would assist you in this role.
    
    Areas of knowledge are as follows:
    
    
    • risk management
    • performance management
    • human resources management
    • internal and external auditing
    • financial reporting
    • accounting
    • management control frameworks
    • internal financial controls
    • governance of organisations and business operations
    • compliance
    • fraud and corruption control
    • strategic planning
    • service reviews and business improvement
    • performance data measurement
    • information technology
    *
14. Please outline your understanding of, or experience in, local government operations.*
15. Please outline your understanding of the role of corporate governance in organisations.*
16. Please describe your current or prior experience on similar committees.*
17. Please list any clubs, organisations, interest groups or committees that you are a member of or have affiliations within the Bathurst Regional Council area.*
18. Are you an undischarged bankrupt or have you been charged with or convicted of a serious criminal offence?*

    1. Yes
    2. No
19. Please provide contact details of two references in support of your Expression of Interest.*