Department of Transport,
Planning and Local Infrastructure
GEOGRAPHIC PLACE NAMES ADVISORY PANEL
1 Spring Street
Melbourne Victoria 3000 Australia
Telephone: 03 9208 3333
www.dtpli.vic.gov.au
DX210292
The Minister for Planning, via the Registrar of Geographic Names is seeking to fill a number of
member vacancies on the Geographic Place Names Advisory Panel.
This application package for candidates provides more information about the Geographic Place
Names Advisory Panel and about government policies which apply to people applying for
appointment (or re-appointment) to boards and committees supported by the Department of
Transport, Planning and Local Infrastructure (DTPLI).
Potential appointees to Government Boards and Committees are required to undertake probity
checks, and as part of your expression of interest, it is necessary for you to provide further
information and your consent in order for these checks to be carried out.
The information enclosed also contains useful tips for completing required application forms. Please
read this information carefully.
Enclosed are six items for your attention and completion:
1.
2.
3.
4.
5.
6.
Geographic Place Names Advisory Panel Appointment Process
Roles and Responsibilities of the Geographic Place Names Advisory Panel
Information for Candidates
Privacy Collection Notice and Consent - The attached consent form identifies the information
about you that DTPLI will hold to process your application.
Declaration of Private Interests– which asks you to list any private interests you may have and
to respond to a series of probity questions.
Curriculum Vitae (with CV coversheet) – in the format required by DTPLI.
Please complete all forms electronically, then print and sign by hand. The forms will pre-populate
some data, and can be navigated using the arrow keys on your keyboard to move between fields.
Once you have completed the forms, please sign and return the printed documents with a covering
letter addressing the selection criteria to:
John Tulloch
Registrar of Geographic Names
Office of Surveyor-General Victoria
Department of Transport, Planning and Local Infrastructure
GPO Box 527
MELBOURNE VIC 3001
Expressions of interest close on Monday, 24 March 2014.
If all or part of the requested information is not provided this may impact on your application.
If you require any assistance in completing the forms or have any questions, please contact Rafe
Benli on (03) 8636 2581.
DTPLI APPOINTMENTS
Geographic Place Names Advisory Panel
Appointment Process
The Minister for Planning, via the Registrar of
Geographic Names is seeking to fill a number of
member vacancies on the Geographic Place Names
Advisory Panel.
The new member(s) will be appointed (until August
2018) pursuant to s.14(1) of the Geographic Place
Names Act 1988 (the Act) by the Minister for
Planning, the Hon. Matthew Guy MLC. The Act does
not specify the number of members of the Panel.
There are currently 20 Panel members.
The Appointment and Remuneration Guidelines for
Victorian Government Boards, Statutory Bodies and
Advisory Committees July 2011 (updated July 2012)
encourage the need to ensure a regular turnover of
members and injection of fresh ideas and enthusiasm
to be balanced against the need to retain a
proportion of members with the necessary skills and
expertise. Further, consideration is given to the
gender balance and diversity of all government
boards and committees in accordance with the
Victorian Government’s commitment to ensuring the
diversity of the boards represents the diversity of our
communities.
Selection Criteria
Under s.14(2) of the Geographic Place Names Act
1998 the panel should comprise, so far as is possible,
persons with knowledge, background or experience
in the following areas:
Mapping or geography;

Urban and regional planning;

Local government administration;

Aboriginal culture and language;

Heritage or historical matters; and

Orthography or linguistics
The Panel is established to ensure that the required
range of knowledge and expertise, from which an
advisory committee can be drawn, is available.
Selection Process
Expressions of interest for Panel members have also
been circulated to relevant organisations and industry
groups.
Applications close at 5.00pm on Monday 24
March 2014.
A selection panel has been established to consider
expressions of interest received and all new
applicants who are short-listed will be interviewed to
assess their suitability for membership of the Panel.
It is expected that the interviews will be undertaken
with short-listed candidates in the week commencing
7 April 2014.
Following the interview process the Minister will be
informed of the short-listed candidates and will make
a final appointment decision. Candidates will be
informed of the outcomes of the appointment
process as soon as possible following the Minister’s
decision.
DTPLI APPOINTMENTS
Roles and Responsibilities of the
Geographic Place Names Advisory Panel
Roles of the Panel
Complete details concerning the role of the Panel and
the Registrar of Geographic Names (the Registrar)
can be found in Section 1.5(F) of the Guidelines for
Geographic Names (2010) Version 2 (the Guidelines)
available from www.dtpli.vic.gov.au/property-andland-titles/naming-places/guidelines.
A summary of the Guidelines related to the Panel has
been included below for your information.
Committees of the Panel
Advisory Committees are convened by the Registrar,
as required, from the Panel. Any specific committee
must consist of no fewer than three members and
may be larger, depending on the range of issues to
be considered.
Advisory Committees are responsible for providing
expert advice and recommendations on
nomenclature issues of regional, state and national
significance and geographic place names policy and
principles. Where a local governing body has not
been able to determine a name, but has used its best
endeavours to do so, the matter may be referred by
the Minister to the Registrar for consideration by an
the Advisory Committee.
The Panel itself is also available to provide a pool of
expertise to assist the Registrar in policy
development and periodic review of strategies and
administrative systems.
Issues that Advisory Committees
Consider
The majority of cases of geographic place name
determination are undertaken by local governing or
administering bodies (such as local councils who
determine the names of local parks etc.). However,
some places or features to be named are of wider
than local significance, or cross several boundaries.
Some of these cases are decided in cooperation with
the several naming authorities involved (for example,
maybe two or three local councils in conjunction with
Parks Victoria will determine the name of a State
Park which transects land located in three local
government jurisdictions).
In some cases a place or feature is of particular
regional, state or national significance for
administrative, historical, cultural or other reasons.
The following criteria for assessment of cultural
heritage significance have been derived from the
criteria adopted by Heritage Victoria, and are used in
assessing geographic name significance:
The historical importance, association with or
relationship to Victoria’s history

The importance of a place or feature in
demonstrating rarity or unique landscape or
topographic features

The place or features potential to educate,
illustrate or provide further scientific investigation
in relation to Victoria’s cultural heritage

The importance of the place or feature, in
demonstrating social or cultural associations

Any other matter which the Minister considers
relevant to the determination of place or feature
significance e.g. major sporting, recreational, or
tourist landscape features.
For example, a place may be a tourist precinct or a
feature of particular interest for tourism, or it may be
of particular significance for administrative or
emergency services purposes. In these cases the
wider Victorian community has an interest in, and a
role in the process of assigning of the place/feature
name.
Those instances where a place or feature is assessed
as ‘significant’ are referred by the Registrar of
Geographic Names to an Advisory Committee. The
input of the relevant local government bodies are
sought and considered by the Advisory Committee
before it makes final recommendations to the
Registrar. The Registrar then adopts the
recommendations of the Advisory Committee and
reports the results to the Minister.
DTPLI APPOINTMENTS
Information for Candidates
Introduction
Curriculum Vitae
This information sheet summarises Victorian
Government policies which apply to people applying
for appointment (or reappointment) to Department of
Transport, Planning and Local Infrastructure public
entities, advisory boards and committees. It also
contains useful tips for completing the enclosed
application forms.
Each applicant is required to provide a personal CV
which includes the following information:

Full name and address

Employment history including position held and
responsibilities of the role

Details of formal qualifications
Appointee Declaration

Each person seeking appointment (or reappointment)
to a public entity must complete an Appointee’s
Declaration. When completing this form, please note:
Current membership of Commonwealth and
Victorian government public entities, statutory
bodies or advisory committees

Current membership of non-government bodies.

the return period is from the start of the last full
financial year to the date the declaration is
completed;

where information regarding income is sought,
only the source of income is required, not the
amount received;

where information about shares or other
securities is sought, no information about the
value or number of shares held needs to be
declared, only the name of the body for which
the shares/securities are held.
Conflict of Interest
Conflicts are not limited to personal or private
interests. The State Services Authority’s “Director’s
Code of Conduct” and “Conflicts of Interest Policy
Framework - Victorian Public Sector” highlight the
imperative to avoid placing yourself in a position of
conflict of interest (see www.ssa.vic.gov.au).
Circumstances sometimes provide for a potential for
conflict of interest, undue influence, or a reasonable
perception that a conflict may exist. You should
identify these situations if they arise, and avoid any
risk of actual or perceived impropriety. If you have
any doubts about a possible conflict, you should
discuss the matter with either your Departmental
contact or the Chairperson.
The CV should be typed, signed by the applicant and
dated.
Curriculum Vitae Cover Sheet
Applicants are asked to complete the CV cover sheet,
which seeks specific information about each
candidate and consent for their curriculum vitae to
be shared with other departments in limited
circumstances, as necessary to consider and make
appointments.
Required Probity Checks
People seeking appointment must undergo the
following checks to the satisfaction of the Minister:

Australian Securities and Investment Commission
(ASIC) check;

Insolvency Trustee Services Australia (ITSA)
check; and

a National Police Record check.
ASIC and ITSA checks
The Department uses information provided by you to
undertake the ASIC and ITSA checks. Applicants
should be aware that these checks will be
undertaken.
National Police Record check
The Department of Transport, Planning and Local
Infrastructure will use the PRM Group to conduct
National Police Record checks on all short-listed
candidates.
Applicants short-listed for interview will be required
to provide consent to conduct these checks and
complete an application and also provide 100 points
of identification.
Copies of the identification must be certified and
provided with your completed application form.
Information Privacy Act 2000
The Information Privacy Act 2000 requires
Government agencies to gain consent to collect
sensitive data such as racial or ethnic origin,
membership of political, professional or trade
associations and criminal records for the purpose of
administering appointments to a public entity. By
voluntarily providing information for the purpose of
appointing you to a public entity, it is considered that
you have consented to the collection of this sensitive
data.
You are able to access the data that the Department
holds about you by contacting:
The Privacy Officer
Department of Transport, Planning and Local
Infrastructure
GPO Box 2797
Melbourne VIC 3001
(03) 9208 3169
The enclosed “Privacy Consent Form” details the
reasons why your information is collected and
provides an opportunity for you to consent to share
your information for the purposes of being
considered for appointment to other public entities,
advisory boards and committees.
Conditions of Appointment
Time Commitment
The Registrar appoints Panel members to Advisory
Committees when required. There are currently four
committees considering naming issues of State
significance. These committees usually undertake
research work outside of meeting times and meet
when required, which is usually every two or three
months.
Each meeting requires a time commitment of one
half-day, and members are usually given two weeks
notice of a meeting being convened.
In addition, there are occasional events or meetings
which members will be invited to attend at their own
discretion. An example of this type of event includes
naming ceremonies or launches, and they are held
every three or four months.
Candidates should note that appointees are generally
expected to attend at least 75 per cent of meetings
and should give careful consideration to the time
commitments required for the position.
Remuneration and Expenses
Candidates, other than public sector employees
(PSEs) and statutory officeholders, may be entitled to
receive remuneration and expenses for their service
on a public entity. Fees are payable to PSEs in
limited circumstances.
A broad definition of PSE has been adopted for the
purpose of determining eligibility for remuneration,
which includes employees of a government
department, statutory body, instrumentality or board,
local government agency, as well as members of
academic staff at any Australian institution of higher
education, and employees of any other public entity.
Public Sector Employees
As a matter of Government policy, PSEs who apply
for appointment to a public entity are only entitled to
receive remuneration for their service if:

they are not the holder of an executive officer or
equivalent position (see below); and

the duties to be performed for the public entity
are outside of the applicant’s public sector duties;
and

there are no material conflicts between the
applicant’s substantive public sector employment
and the duties required to be performed on the
public entity.
Executive officer equivalent positions include
positions where the PSE’s employment is governed
by Government Sector Executive Remuneration Panel
(GSERP) policies or the PSE’s minimum total
remuneration/salary package is within the VPS
Executive Remuneration Bands. As at 1 July 2013 the
minimum threshold for Executive Remuneration in
the VPS is $145,209. The current thresholds can be
confirmed on the State Services Authority website
(http://www.ssa.vic.gov.au/executiveremuneration/public-service.html).
A PSE who wishes to be remunerated for service on a
public entity must obtain written confirmation from
their substantive public sector employer that they
have approval to perform the duties on the public
entity, and confirmation that those duties can and
will be performed in the applicant’s own time.
A PSE’s entitlement to receive remuneration may be
further limited by the Act which establishes the
particular public entity for which the appointment is
sought. For further information, please refer to the
relevant Act.
Further Information
Relevant Background Reading
The State Services Authority’s website
(www.ssa.vic.gov.au)provides governance and policy
information for public entity candidates and
Directors.
The Appointment and Remuneration Guidelines for
Victorian Government Boards, Statutory Bodies and
Advisory Committees are available on the
Department of Premier and Cabinet website
(http://www.dpc.vic.gov.au/index.php/resources/gov
ernance/appointment-and-remuneration-guidelines).
Relevant Victorian legislation can be accessed at
www.legislation.vic.gov.au.
Help and Assistance
If you require assistance in completing any of the
enclosed forms, or have any other questions about
the application and appointment process, please
contact Rafe Benli on (03) 8636 2851.
DTPLI APPOINTMENTS
Privacy Collection Notice and Consent
Geographic Place Names Advisory Panel
I, [Full Name] have expressed interest in being an
appointee to the Geographic Place Names Advisory
Panel and understand that the Department of
Transport, Planning and Local Infrastructure and the
State Services Authority may collect and hold certain
personal information about me including:

my name and address;

my date of birth and age;

my gender;

whether I live in rural or regional Victoria;

whether I identify as an Aborigine or Torres
Strait Islander;

whether I, or my parents, were born outside
Australia;

whether I speak a language other than English at
home; and

whether I have a culturally diverse background
other than that indicated in the previous
questions.
I understand that I can seek access to personal
information collected about me and can request the
Department/Agency or the State Services Authority
to correct and update it.
Purpose of collection
I understand that the information is being collected
and used to:

process and assess my application for
consideration of the appointment;

enable the Victorian Government to monitor the
diversity of appointments to and composition of
statutory and other bodies to which the
Government may make appointments;

manage dealings with me (for example to
contact me or to provide me with other
information from time to time); and

be included in the State Services Authority’s
appointments database, a secure system for
storing information about public entities and
members of public entity Boards, Committees
and Councils (this system is managed by the
State Services Authority and hosted on a secure
government server).
This information is subject to the Information Privacy
Principles (IPPs) found in the Information Privacy Act
2000 (IP Act).
Under IPP 1, the Geographic Place Names Advisory
Panel, DTPLI and the State Services Authority must
take reasonable steps to ensure that I am aware of:
For these purposes I understand that the information
is usually disclosed to:

the body’s contact details and how to contact it;


the fact that I am able to get access to personal
information about me;
any Department and authorised officers
nominated by the Secretary of the Department or
his or her delegate;

the purposes for which the information is
collected;

authorised officers of the State Services Authority
(nominated by the CEO of the State Services
Authority or his or her delegate);

to whom that information is usually disclosed;


any law requiring the information to be collected;
and
the Department of Premier and Cabinet for use
only for the purposes of annual reporting;


the consequences for me if the information is not
collected.
the Cabinet or any member of it for use only for
the purposes of annual reporting;
I have read the notice under IPP 1.3 which is
provided with this consent form.
I am aware of the contact details for the Department
of Transport, Planning and Local Infrastructure and
the State Services Authority.
Geographic Place Names Advisory Panel
[Full Name]


if I expressly consent, my personal information
will be shared for the purpose of considering
appointments to other public sector entity boards
with other departments and agencies, and may
be used by the Department of Human Services to
maintain the Victorian Women’s Register or the
Office of Aboriginal Affairs to maintain the
Wayaperri Register; and
as otherwise used in accordance with the IP Act.
Information on the appointments database is used
for the following purposes:

to enable the Victorian Government to monitor
the diversity and profile of appointments to and
composition of public sector entity Boards to
which the Government may make appointments;

to allow the State Services Authority to use
information on the appointments database for
research purposes and to plan improvements to
governance processes for Victorian public sector
entity Boards; and

to allow the State Services Authority to draw
select and limited information (described below)
from the appointments database and for this
select and limited information to be made
publicly available on a Victorian Government
website.
I understand that, for reasons of personal safety, the
composition of some public sector entity Boards will
not appear on a Victorian Government website, and
that I can discuss this with the Secretary of the
Department or his or her delegate if I think this is
relevant to me.
I understand that my refusal to consent to the
collection and disclosure of information described in
this consent form may impact on my being
considered for an appointment and may result in
greater difficulty for Departments/Agencies in
monitoring the diversity of board appointments and
their composition.
NOTICE UNDER INFORMATION
PRIVACY PRINCIPLE 1.3
The Department of Transport, Planning and Local
Infrastructure treats all personal information provided
by an individual in support of an appointment
application in accordance with the Information
Privacy Act 2000, the Health Records Act 2001 and
the Public Records Act 1973.
The IP Act obliges the Geographic Place Names
Advisory Panel to advise you of certain facts
regarding the collection and management of
Geographic Place Names Advisory Panel
[Full Name]
information relevant to your expression of interest for
appointment.
If you accept appointment to the Geographic Place
Names Advisory Panel, the Department of Transport,
Planning and Local Infrastructure and the State
Services Authority will hold the information about you
identified in this consent form. The information will
be collected and used for the purposes identified in
this consent form and will usually be disclosed to the
persons and bodies identified in this consent form.
This information is accessible to you at any time, and
can be obtained by making a request to:
The Privacy Officer
Department of Transport, Planning and Local
Infrastructure
GPO Box 2797
Melbourne VIC 3001
(03) 9208 3169
foi@dtpli.vic.gov.au
The information is collected and used for the
purposes identified in this consent form and will not
be disclosed to any other person or body other than
those identified in this consent form, or where
authorised or required by law.
The Geographic Place Names Advisory Panel, the
Department of Transport, Planning and Local
Infrastructure and the State Services Authority have
implemented technology and security policies, rules
and measures to protect the personal information
that it has under their control from unauthorised
access, improper use, alteration, unlawful or
accidental destruction and accidental loss. The
Geographic Place Names Advisory Panel, the
Department of Transport, Planning and Local
Infrastructure and the State Services Authority will
remove personal information from their systems
when it is no longer required (except in accordance
with the Public Records Act 1973).
Refusal to provide and consent to the use of the
personal information sought for the appointment
process may result in greater difficulty in monitoring
the diversity of board and other bodies’ appointments
and their composition.
Consent
I consent to the Department of Transport, Planning
and Local Infrastructure and the State Services
Authority collecting, using and holding that
information, and releasing it to the Victorian
Government Department or Departments or Agencies
responsible for that body in accordance with the IP
Act for the purposes outlined in this consent form.
I agree / do not agree to the Department sharing
my information with other Victorian Government
Departments for the purposes of enabling the
relevant Minister to consider me for appointment to
other boards and committees.
I understand that recipients of information about me
provided as a result of this consent will remove as far
as practicable any potential means of identifying me
individually under their reporting requirements.
I consent to the following information being made
publicly available in a Victorian Government website:

my first name and surname;

the term of my appointment; and

my status as a member or chairperson.
I may have provided information about other
individuals in my curriculum vitae and any other
documentation included in my application. I
acknowledge that when I provide personal
information about other individuals such as referees,
the Geographic Place Names Advisory Panel and the
Department of Transport, Planning and Local
Infrastructure relies on me to make those other
individuals aware that such information will or may
be provided to the Victorian Government, the
relevant purposes that Victorian Government will use
it for, and how they can access it.
I wish to advise that the following restrictions apply
to the distribution of the information I have provided
to you:
Insert here restrictions (if any) that apply to the use
or disclosure of your information
Geographic Place Names Advisory Panel
[Full Name]
Signed:
______________________________
[Full Name]
Date:
_____ /_____ /_____
Witness:
______________________________
DTPLI APPOINTMENTS
Declaration of Private Interests
Geographic Place Names Advisory Panel
How to complete this declaration
Please complete the form as accurately and comprehensively as possible. Please type or write your answers in
block capitals, and provide an answer for each question. Do not leave any questions blank.
Conflicts of Interest (A7)
Conflicts of interests can be actual, potential or perceived, and should be declared to ensure that any risks are
managed. Detailed guidance can be found on the State Services Authority website in its Conflict of Interest Policy
Framework – www.ssa.vic.gov.au and in its eLearning guide on Conflicts of Interest.
Findings of Guilt (B6)
A “finding of guilt” includes convictions, fines associated with criminal charges, good behaviour bonds,
undertakings and community based orders, even where no conviction was recorded. It does not include a
conviction under any prescribed spent convictions scheme.
A. Private interests
A1. Other significant sources of income:
YES / NO
Do you have income from any sources other than your main
source of employment income relating to:
If YES, enter relevant information here:

contracts;

offices held in return for payment or other reward; or

a trade, vocation or profession engaged in by you?
If YES, please provide details.
A2. Office holder:
YES / NO
Do you hold office in any public or private:
If YES, enter the relevant information here:

company?

trustee company?

incorporated association?

other entity?
If YES, enter the name of the organisation, and the office you
hold.
Geographic Place Names Advisory Panel
[Full Name]
A. Private interests
A3. Shareholdings and other business
interests:
YES / NO
If YES, enter relevant information here:
Do you or does a member of your family have any
shareholdings, investments or other business?
(This includes a company, partnership, association or other
entity, as well as nominee shareholders on behalf of the agency
in government companies.)
If Yes, please provide details of the name, nature of operations
and the nature of the interest of all such holdings of which you
are aware, which could reasonably raise an expectation of
conflict of interest, or a material interference with your public
duties.
Where the State determines that there is any material
conflict, an appointment may not proceed or your
appointment/employment may be suspended whilst the
particular interest remains.
A4. Trusts:
YES / NO
Are you:
If YES, enter relevant information here:

a beneficiary of any trust? If so, who is the trustee?;

the trustee of any trust?; or

the director of a trustee company in which a member of
your family is a beneficiary?
If Yes, please provide the name and nature of the operations of
the trust(s) of which you are aware, which could reasonably
raise an expectation of conflict of interest, or a material
interference with your public duties.
A5. Real Estate:
YES / NO
Do you or a member of your family own any real estate
(including your principal place of residence)?
If YES, enter all relevant information here:
If Yes, please provide details of the location and purpose of any
real estate owned (eg, principal place of residence, investment
property etc) which could reasonably raise an expectation of
conflict of interest, or a material interference with your public
duties.
Geographic Place Names Advisory Panel
[Full Name]
A. Private interests
A6. Agreements:
YES / NO
Have you or a family member entered any contract, agreement
or understanding that gives rise to:
If YES, enter all relevant information here:

an obligation; or

an expectation of reward, e.g. an agreement about future
employment once your appointment term is completed.
If Yes, please provide details of which you are aware, which
could reasonably raise an expectation of conflict of interest or a
material interference with your public duties.
A7. Other financial interests:
YES / NO
Do you or a member of your family have any other significant
financial or other interests that:
If YES, enter all relevant information here:

have been held;

are currently held; or

will accrue
of which you are aware, which could reasonably raise an
expectation of a conflict of interest or material interference with
your public duties. If Yes, please provide details.
Examples of a substantial financial or other interest include:

being a principal or key employee of a material professional
adviser supplying services; and

interests in contracts, trusts or other business arrangements
not already covered in this declaration.
A8. Other interests:
YES / NO
Are there any other arrangements or circumstances not already
covered to declare which could constitute a conflict of interest?
If YES, enter all relevant information here:
Geographic Place Names Advisory Panel
[Full Name]
B. Probity
B1. Bankruptcy
YES / NO
Have you been declared bankrupt or been the subject of any
order under the Bankruptcy Act 1966 (Cth)?
If YES, enter all relevant information here:
B2. Insolvency
YES / NO
Have you been a director or executive officer of a corporation
which became insolvent whilst you were a director or executive
officer?
If YES, enter all relevant information here:
B3. Disqualification
YES / NO
Have you ever been disqualified from acting as a director or
acting in the management of an incorporated association?
If YES, enter all relevant information here:
B4. Corporate contraventions
YES / NO
Have you ever:
If YES, enter all relevant information here:

contravened any civil penalty provision under the

Corporations Act 2001 (Cth) or any of its predecessors;
contravened the Associations Incorporation Act 1981 (Vic)
or any equivalent in another jurisdictions; or

been found guilty of any offence in relation to corporate or
regulatory matters?
Geographic Place Names Advisory Panel
[Full Name]
B. Probity
B5. Criminal or Civil Proceedings
YES / NO
Are you currently a party in any capacity in either criminal or
civil proceedings before a:
If YES, enter all relevant information here:

court:

tribunal; or

other adjudication body, including a professional,
registration or licensing body,
which could reasonably raise an expectation of a material
interference with your public duties?
Do you expect to become a party to any such proceedings in
the next year?
B6. Findings of Guilt
YES / NO
Has there ever been a finding of guilt against you for a criminal
offence (except a conviction that is spent under any prescribed
spent convictions scheme)?
If YES, enter all relevant information here:
B7. Subject to investigation
YES / NO
To the best of your knowledge and belief have you been, or are
you currently, the subject of any inquiry or investigation,
including those by:
If YES, enter all relevant information here:

a department or agency of the Commonwealth, a State, or
a Territory of Australia; or

a professional association; or

a regulatory agency; or

a current or previous employer; or

a consumer protection organisation?
(contd...)
Geographic Place Names Advisory Panel
[Full Name]
Consent and Declaration
The Department treats all personal information provided by an individual in support of an appointment application
in accordance with the Information Privacy Act 2000 (Vic) and the Public Records Act 1973 (Vic). The personal
information you provide in this form is required for application processing and assessment purposes, including
submission to Cabinet. It may be shared with other public sector organisations.
Should you wish to gain access to your personal information held by the Department please contact the
Department’s Privacy Officer at:
Department of Transport, Planning and Local Infrastructure
GPO Box 2797
Melbourne VIC 3001
(03) 9208 3169
foi@dtpli.vic.gov.au
When you provide us with information about other individuals, we rely on you to make them aware
that such information will or may be provided to us as part of the application process, and to obtain
their consent to that disclosure.
If all or part of the requested information is not provided this failure may impact on your application.
Declaration
I, [Full Name] in relation to my application for appointment to the Geographic Place Names Advisory Panel:

consent to the Department of Transport, Planning and Local Infrastructure collecting and using this information
on a confidential basis as described in this form and for the purposes of administering appointments to the
Geographic Place Names Advisory Panel; and

declare that to the best of my knowledge, the information I have provided in Part A and Part B of this
declaration is true and correct; and

undertake to advise the responsible Agency Head or delegate in writing if an actual, potential or perceived
conflict arises in the future and to stand down in any decision-making process in which I may be compromised;
and

undertake to advise the responsible Agency Head or delegate of any alterations or additions to my declaration
as soon as practicable if there is any change to the interests set out in Part A or to the answers set out in
Part B of this declaration.
Signed: ___________________________________
Date:
Witness:
________________________________
[Full Name]
Witness Name:
_____ /_____ /_____
Date:
Geographic Place Names Advisory Panel
[Full Name]
_____ /_____ /_____
DTPLI APPOINTMENTS
Curriculum Vitae Coversheet
Geographic Place Names Advisory Panel
Mandatory Personal Information
Optional Personal Information
Title:
Choose an item.
Full Name:
[Full Name]
Sex:
Male / Female
Date of Birth:
Click here to enter text.
Answering the following questions is optional. If you
provide this information, it will be used by DTPLI, the
Department of Premier and Cabinet, and the State
Services Authority to measure diversity in
appointments.
Do you identify as Aboriginal or Torres Strait
Islander?:
Yes / No / Prefer not to say
Residential Address:
Suburb STATE PCODE
Business Address:
Were you or one of your parents born overseas?:
Yes / No / Prefer not to say
Country of Birth:
Suburb STATE PCODE
Tel. Business:
Click here to enter text.
Tel. After Hours:
Click here to enter text.
Tel. Mobile:
Click here to enter text.
Email Address:
Click here to enter text.
Click here to enter text.
Do you speak a language other than English at
home?:
Yes / No / Prefer not to say
Do you have a culturally and linguistically diverse
background?:
Yes / No / Prefer not to say
Do you identify as a person with a disability?:
Yes / No / Prefer not to say
Checklist
Please ensure that your CV includes
the following information:
Full name and address
Employment history including position and
responsibilities
Academic and vocational qualifications
Current membership of other government public
entities, statutory bodies, or advisory
committees
Current membership of non-government bodies
(i.e. boards, committees, councils or community
groups)
Signature and date
Geographic Place Names Advisory Panel
[Full Name]
The curriculum vitae should be typed and not
handwritten.
Failure to include the above information may delay
the consideration of an appointment.