Application for Appointment to the of Directors of the South Eastern Melbourne Primary Health Network Limited Personal Details Title: Given names: Family name: Check all which are General Practitioner □ applicable to you: Other (for example, pharmacist, CEO, consumer etc) □ (there are some composition requirements for the Board of Please specify: ________________ Directors as per the Constitution) Contact Details Please only provide details at which you are happy to be contacted in relation to this position. Home phone: Work phone: Mobile phone: E-mail address: Postal address: Current Employment Details (if applicable) Occupation: Employer: Address: Tertiary and Relevant Academic or Professional Qualifications Qualification University / Institute Date awarded Committee or Board Experience Please list any experience on Boards, Board committees or Advisory Committees. Position / Title Organisation Start Date End Date – Memberships Please list memberships of any professional or industry bodies. Membership level Body Start Date
Application for Appointment to the of Directors of the South Eastern Melbourne Primary Health Network Limited Personal Details Title: Given names: Family name: Check all which are applicable to you: (there are some composition requirements for the Board of Directors as per the Constitution) □ General Practitioner □ Other (for example, pharmacist, CEO, consumer etc) Please specify: ________________ Contact Details Please only provide details at which you are happy to be contacted in relation to this position. Home phone: Work phone: Mobile phone: E-mail address: Postal address: Current Employment Details (if applicable) Occupation: Employer: Address: Tertiary and Relevant Academic or Professional Qualifications Qualification University / Institute Date awarded Committee or Board Experience Please list any experience on Boards, Board committees or Advisory Committees. Position / Title Organisation Start Date – End Date Memberships Please list memberships of any professional or industry bodies. Membership level Body Start Date
Board_Application_Form.docx