PREQUALIFICATION SCHEME: AUDIT AND RISK COMMITTEE
INDEPENDENT CHAIRS AND MEMBERS
APPLICATION FORM – July 2015
Submission
This form is to be completed by all applicants to the Prequalification Scheme: Audit and Risk
Committee Independent Chairs and Members. All questions are mandatory unless otherwise
stated. Please be brief but ensure that you provide all relevant details to assist the
Assessment Committee arrive at a determination.
Please email the completed application, as either a word or PDF document to:
auditriskmembers@finance.nsw.gov.au
Please note that hand written applications cannot be accepted.
A) APPLICANT DETAILS
Name
Residential Address
Postal Address
Phone
Web
Mobile
(Optional) - Insert website or
Linkedin profile
Email
Current Employer and ABN
Do you have any specific requests or requirements to be considered by the Assessment
Committee? For example, are you requesting prequalification for a specific Audit & Risk Committee
or Committees?
Application Type
Prequalification as Member only
Prequalification as Member and Chair
Removal of limitation or upgrade of existing
Prequalification from Member to Chair
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AREAS OF EXPERIENCE
Please indicate all areas in which you can demonstrate significant expertise.
B) EXPERIENCE
Ageing and Disability
Housing
Arts
Justice
Central Government – Policy,
Legislation, Public Administration
Primary Industry
Community Services
Public Employment/Workplace Relations
Economic Services
Sport and Recreation
Education
Taxation
Emergency Services
Transport
Environment
Utilities/Telecommunications
Health
FUNCTIONAL EXPERIENCE
Risk Management
Information and Communications Technology
HR
Finance
Insurance
Internal Audit
External Audit
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C) APPLICANT RESUME
Please attach an up-to-date resume as a separate document. This should not exceed 5
pages. A cover letter or statement of intent is not required. However, you may include a
cover letter provided it does not exceed 1 page. Please use default margins and font size.
D) CAPABILITY
You will be assessed against each of the criteria listed below. For each criterion, please
provide a maximum of one page of information which demonstrates your ability to meet the
required capability.
All applicants must complete Part A: Audit and Risk Committee Member. If applying for
prequalification as a Chairperson, please also complete Part B: Audit and Risk Committee
Chair.
Part A:
Audit and Risk Committee Member (to be completed by all applicants)
1) Extensive senior level experience in governance and management of complex
organisations, an ability to read and understand financial statements and a
capacity to understand the ethical requirements of government (including
potential conflicts of interest).
(Please answer in 1 page or less)
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2) Functional knowledge in areas such as: risk management; performance
management; human resources management; internal and external auditing;
financial reporting; accounting; management control frameworks; financial
internal controls; governance (including planning, reporting and oversight); or
business operations.
(Please answer in 1 page or less)
3) A capacity to form independent judgements and willingness to constructively
challenge/question management practices and information.
(Please answer in 1 page or less)
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4) A professional, ethical approach to the exercise of duties; and the capacity to
devote the necessary time and effort to the responsibilities of a Member of an
Audit and Risk Management Committee.
(Please answer in 1 page or less)
5) Possession of a relevant professional qualification or membership is desirable
(e.g. Certified Internal Auditor, Certified Practicing Accountant, Certified
Practicing Risk Manager, Chartered Accountant, Graduate Member of the
Australian Institute of Company Directors.
(Please answer in 1 page or less)
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Part B.
Audit and Risk Committee Chair
If applying for prequalification as an Audit and Risk Committee Chair, please complete
Section B: Audit and Risk Committee Chair.
1. Leadership qualities and the ability to promote effective working relationships
in complex organisations.
(Please answer in 1 page or less)
2. An ability to communicate complex and sensitive assessments in a tactful
manner to chief audit executives, senior management, board members and
Ministers.
(Please answer in 1 page or less)
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3. A sound understanding of:
a) the principles of good organisational governance and capacity to
understand public sector accountability, including financial reporting;
b) the business of government departments or statutory bodies and the
environment in which they operate (or capacity to quickly gain such an
understanding);
c) internal audit operations, including selection and review of chief audit
executives; and
d) risk management principles.
(Please answer in 1 page or less)
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E) AUDIT OR RISK COMMITTEE EXPERIENCE
Please list all relevant Audit or Risk Committee roles, including any Audit and Risk Committees and sub-Committees within the NSW Public Sector.
Organisation
Name of Committee
Role/Position
Start Date
End Date
Please add more rows, if required
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F) APPLICANT REFEREE REPORTS
Please insert the contact details of 2 relevant referees.
Referee 1
Name
Organisation
Position
Phone
Mobile
Email
Referee 2
Name
Organisation
Position
Phone
Mobile
Email
Applicant Referee Reports
The provision of an Applicant Referee Report (please see next page) is not required.
The Department of Finance, Services and Innovation (DFSI) and the Assessment
Committee may request that your nominated referees provide either an oral or written
reference (in the form attached) at a later stage. DFSI will not notify you prior to
contacting your nominated referees.
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Please insert CORPORATE LETTERHEAD of referee’s organisation HERE
(if applicable)
APPLICANT REFEREE REPORT
(to be submitted where requested)
This report may be used to assist in assessing the suitability of an Applicant for the
Prequalification Scheme – Audit and Risk Committee Independent Chairs and
Members.
DFSI or the Assessment Committee may contact the referee to verify or clarify
aspects of this Report
Applicant Name
Organisation Name
Phone
In what context do you know
the applicant (Briefly describe)
Date Commenced
Date Completed
Referee Report
Please provide comments on the applicant’s performance (maximum of 2 pages,
making reference, as appropriate, to the assessment criteria (listed on next page).
Signed
Signature
Name
Date
Tel
Position Title
Mob
email
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Please find below the assessment criteria against which applicants will be
assessed.
Assessment Criteria Part 1 (all applicants)
Extensive senior level experience in governance and management of complex
organisations, an ability to read and understand financial statements and a capacity
1a
to understand the ethical requirements of government (including potential conflicts of
interest).
1b
Functional knowledge in areas such as: enterprise risk management; performance
management; human resources management; internal and external auditing;
management control frameworks; financial internal controls; governance (including
planning, reporting and oversight); or business operations.
1c
A capacity to form independent judgments and willingness to constructively
challenge/question management practices and information.
1d
A professional, ethical approach to the exercise of their duties and the capacity to
devote the necessary time and effort to the responsibilities of a member of an Audit
and Risk Committee.
1e
Possession of a relevant professional qualification or membership (e.g. Certified
Internal Auditor, Certified Practicing Accountant, Certified Practicing Risk Manager,
Graduate Member of the Australian Institute of Company Directors is desirable).
Assessment Criteria Part 2 (only if applying for Chairperson)
Leadership qualities and the ability to promote effective working relationships in
2a
complex organisations.
2b
An ability to communicate complex and sensitive assessments in a tactful manner to
chief audit executives, senior management, board members and Ministers.
2c
A sound understanding of:
 the principles of good organisational governance and capacity to understand
public sector accountability;
 internal audit operations, including selection and review of chief audit
executives; and
 risk management principles.
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G) POTENTIAL CONFLICTS OF INTEREST
The following questions are designed to help you and NSW Government
Agencies determine potential conflicts of interest.
a)
Are you currently employed/engaged by any organisations (excluding
appointments to NSW Government Boards and Committees)? Please detail
the organisation name and position title.
Organisation Name
Please provide details or type "none"
Position Title
Please add additional rows as required
b)
Have you (whether as an individual or employee), undertaken any fee for
service engagements, contracts (including subcontracts) or been otherwise
employed by a NSW Government entity in the last three (3) years (excluding
appointments to NSW Government Boards and Committees). If so, please
specify the agency/agencies, nature of engagement and dates.
Agency Name
Nature of engagement
Please provide details or type "none"
Dates
Please add additional rows as required
c)
Do you hold a significant beneficial interest in any privately held companies
prequalified under any other NSW Government prequalification schemes,
including the Performance and Management Services scheme? If so, please
provide company name, ABN and describe nature of interest in company.
Please provide details or type "no"
d)
Please nominate any real or potential conflicts of interest.
Please provide details or type "none"
Please note that DFSI may inform NSW Government Agencies or other relevant
parties of potential conflicts of interest.
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H) STATEMENT
The information that you provide in this application will be used for the purposes of
assessing and processing your application. Information you disclose may also be
used by DFSI and Treasury to identify potential conflicts of interest and to facilitate
the continued operation, administration and future enhancements to the Scheme.
All information provided to DFSI may be stored in the GOView Database, maintained
by the Department of Premier and Cabinet. NSW Government Departments and
Statutory Bodies will be provided with access to the GoView Database for the
purposes of identifying potential candidates and making appointments to Audit and
Risk Committees.
State Owned Corporations may, on special request, also be provided access to the
GoView Database for the purpose of identifying potential candidates and making
appointments to Audit and Risk Committees or Boards.
Applicants may request that their information be “Restricted” and only be made
available to specific agencies.
I agree to disclose my personal information and CV to NSW Government
Departments, Statutory Bodies and State Owned Corporations seeking to engage
Independent Chairs or Members.
Please
tick
OR
I only agree to disclose my personal information and CV to specified agencies for the
purpose of being engaged as an Independent Chair or Member:
Please specify the agencies below:
I hereby confirm the completeness and authenticity of the information provided in this
application and will act in accordance with the Scheme Conditions.
Signature of Applicant
Applicant Name
Date
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APPLICATION CHECKLIST
Please use the following checklist to ensure that your application is complete.
Item Mandatory Criteria and Requirements
A
Applicant Details
B
Experience
C
Resume (attached as a separate document)
D.1
Applicant Capability - Part A (all applicants)
D.2
Applicant Capability – Part B (only if applying as Chairperson)
E
Audit and Risk Committee Experience
F
Contact details for 2 referees
G
Potential conflict of interests
H
Statement
Completed
Submission:
Please email the completed application to auditriskmembers@finance.nsw.gov.au
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