APPLICATION FORM NAME ADDRESS SUBURB POSTCODE EMAIL PHONE MOBILE DATE OF BIRTH GENDER OTHER DO YOU SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME? YES NO IF YES PLEASE TELL US WHICH LANGUAGE? DO YOU IDENTIFY ABORIGINAL OR TORRES STRAIT ISLANDER YES NO AS: LGBTIQ YES NO IS THERE ANYTHING THAT MIGHT MAKE IT DIFFICULT FOR YOU TO APPLY OR PARTICPATE AS A BOARD MEMBER THAT WE SHOULD BE AWARE OF? EMPLOYMENT: Full time Part time Casual Self employed Name of main employer: Retired Disability pension Unemployed Home duties Full time study Part time study Volunteer Carer Name of educational institution:
APPLICATION FORM NAME ADDRESS SUBURB POSTCODE EMAIL PHONE MOBILE DATE OF BIRTH GENDER OTHER DO YOU SPEAK A LANGUAGE OTHER THAN ENGLISH AT HOME? YES NO IF YES PLEASE TELL US WHICH LANGUAGE? DO YOU IDENTIFY AS: ABORIGINAL OR TORRES STRAIT ISLANDER YES NO LGBTIQ YES NO IS THERE ANYTHING THAT MIGHT MAKE IT DIFFICULT FOR YOU TO APPLY OR PARTICPATE AS A BOARD MEMBER THAT WE SHOULD BE AWARE OF? EMPLOYMENT: Full time Part time Casual Self employed Name of main employer: Retired Disability pension Unemployed Home duties Full time study Part time study Volunteer Carer Name of educational institution:
BHAC-Board-Application-2018.docx