13.5 - Attachment 4






Expression of Interest for Community Membership





1. Name of Committee/ Board (Facility):      


2. Your Name:      


3. Are you representing a Group or Organisation: Yes     No

    If “Yes” please advise name of Group/Organisation:      


4. Postal Address:      



5. Telephone Numbers:          Preferred            


6. Email Address:             

Note:  All communication will be by Email.

7. Please outline why you would like to be a member of this Committee:





8. Personal attributes and qualifications you will bring to this Committee. Please outline how you meet the following criteria:

·    Have established ties to the Byron Shire community, and

·    Experience (professional, amateur, volunteer) working in either; venue management, event management, conference organising, music promotion, theatre production, design, marketing, or related technical areas such as accounting, managing people or business, community services or groups or fundraising.








9. Are you interested in an Office Bearer’s position on the committee (Chair, Vice Chair, Secretary, Treasurer, Bookings Officer). If so, please outline the skills or experience you would bring to such a position.





10. Past experience on Council’s Committees (if any):  Please list name of Committee(s) and period of service.






11. Any other information you wish to include:




ATTENTION: Applicant - Privacy Notification Form

The personal information that Council is collecting from you is personal information for the purposes of the Privacy and Personal Information Protection Act 1998 (“the Act”). The information may only be made available through this or other relevant Acts and Regulations that may apply.

The intended recipients of the personal information are:

à  officers within the Council;     à  agents or data service providers engaged by the Council                                à Council agendas

The supply of the information by you is voluntary.  If you cannot provide or do not wish to provide the information sought, the Council will be unable to process your application. 

Council is collecting this personal information from you in order to process this committee nomination.

If elected to a committee

à  Your name will also be printed in the reports of Committees and published on Council’s Web Page
à  Your name and contact details may be made available to other committee members

You may make application for access or amendment to information held by Council.  You may also make a request that Council suppress your personal information from a public register.  Council will consider any such application in accordance with the Act.  Enquiries concerning this matter can be addressed to the Information Service Department of Council.  Council is to be regarded as the agency that holds the information.



Signed Applicant …………………………………………….……..                                                        Dated………………………………