EXPRESSION OF INTEREST FOR APPOINTMENT
Please complete this application form, attach a current curriculum vitae and send to
boardappointments@transport.govt.nz.
Position applied for
If you have been
nominated, please
identify by whom
Title
Full Name
Address
(Street address not postal)
Contact details
Home telephone:
Work telephone:
Mobile phone:
Email address:
Citizenship (if not NZ)
Ethnicity (please state
iwi affiliations if Māori)
Current or most
recent employment
(position and employer,
including years)
Qualifications and
experience
(include relevant work
history and community
involvement)
1
Government board
member or director
experience (if any)
Current
(include years)
Previous
Private and/or
voluntary sector
board experience (if
any)
Current
(for example, School Trust
Board or Māori Land
Incorporation)
Previous
(include years)
Suitability for the
position – please
provide a personal
statement describing what
attributes you would bring
to the position
2
Referees
Name
Address
Phone and email
Relationship to you
Name
Address
Phone and email
Interests
Relationship to you
List details of all relevant employment, significant directorships/ memberships
and trusteeships, as well as memberships of other organisations, or voluntary
interests in business enterprises, professional practices, personal associations
and relationships with other groups or organisations that could constitute an
actual, potential or perceived conflict of interest.
I confirm that I have:
no actual, potential or perceived conflicts of interest to be declared
actual, potential or perceived conflicts of interest, as detailed below:
Proposals for conflict management (if applicable)
Authority and
declaration
I authorise the named referees to disclose information about my suitability for
appointment to this board to the Ministry of Transport.
I have read all information provided about the role, and have disclosed all actual
or potential or perceived conflicts of interest, and all personal information
relevant to my appointment.
I have completed all sections of the application form and the information
supplied in this application is correct. I acknowledge that incorrect or missing
information will render this application invalid.
Signed
Date
3