Heritage Council of WA

Heritage Council of WA

Nomination Form
Sender
Nominations are sought from persons having qualifications, experience or knowledge in matters relating to the functions of the Heritage Council of Western Australia
Collection notice
The Department of Planning, Lands and Heritage is obliged to advise you of certain matters when collecting your personal information. This collection notice sets out those matters and explains how we will manage the collection, use and disclosure of your personal information.

The Department collects this information on behalf of the Minister for Heritage to assist in assessment of nominees for appointment to the Heritage Council under Section 14 of the Heritage Act 2018.

Additionally, we may use information you provide:
- to communicate with you;
- to inform biographical material should you be appointed to the Council; and
- to verify your identity.
We will seek your consent to use your personal information for any secondary purpose that is not outlined in this notice.

If you choose not to provide your name and contact details, we will not be able to process your nomination.

We may share this information with:
- officers within the Department of Planning Lands and Heritage;
- nominated members of the assessment panel;
- the Minister for Heritage and supporting officers; and
- other government agencies for assessment, reporting, advice or comment.
See our Privacy Policy for further information, including how to make a privacy complaint and how to access or correct your personal information.

If you have any questions about how your personal information will be handled, you can contact us using one of the methods below:

Department of Planning, Lands and Heritage
Phone: (08) 6551 8002
Email: HCWAAgendas@dplh.wa.gov.au
Online form: General enquiry form
Nominee details
Title
If Other, please specify
Full Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Phone Number

Area CodePhone Number
Are you of Aboriginal or Torres Strait Islander descent? (Please select all that apply)
What is your country of birth?
Is a language other than English spoken at home?
Do you have any medical conditions, injuries, or disabilities that may impact on your ability to undertake the position
If 'Yes', please give details:
*Please note, disclosure of an illness, injury or disability will not exclude an applicant.
Do you have any current convictions for any offences from any court, or are you currently the subject of any charge pending before any court? You do not need to give details for any conviction which you have had declared spent (West Australian Spent Convictions Act 1988). A criminal record does not necessarily disqualify an applicant.
If 'Yes', please give details:
Are you currently employed in the West Australian Public Sector?
If 'Yes', please give details:

References

Please provide the contact details for two current referees that can be contacted for verification of the claims made in this application.
Referee 1

First NameLast Name
Organisation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Email
Referee 2

First NameLast Name
Organisation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Email
Nominee declaration
I confirm that all the information contained within this application is correct.
Full Name
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Signature
Should be Empty:

Collection notice

Nominee details

Skills and experience

References

Nominee declaration