This document is to be used for individuals applying for appointment to the Pharmacy Business Ownership Council. The information is sought to assist in assessing your eligibility and suitability for nomination and/or appointment.

To apply you must:

Complete this application form
Provide a Covering Letter (Member - maximum 2 pages, Deputy Chairperson - maximum 3 pages)
Provide a current Curriculum Vitae (maximum 2 pages, PDF preferred)

Privacy Information

Your personal information will be treated as confidential and will only be used or accessed by authorised persons for purposes connected with your current candidacy for appointment and, should you be successful in appointment, to ensure an accurate record of nominees and appointees to statutory bodies.

Personal information collected by the Department of Health (or its Suppliers such as a specialist recruitment agency) is handled in accordance with the Information Privacy Act 2009. The personal information provided by you will be securely stored and made available only to appropriately authorised officers. Personal information recorded on this form will not be disclosed to other parties without your consent, unless required by law.

Personal information may be disclosed as part of the recruitment process, for example, in contacting referees or obtaining certification from relevant parties for public sector employees.

Diversity commitment

To reflect the diversity within the communities and people we support and serve, we seek to identify nominees that are both representative and diverse. With a focus on inclusion, accessibility and flexibility, we are committed to supporting you in this application process. If you require any assistance or adjustments to this application process to enable you to apply for the advertised role, please contact Will Wilson at Watermark Search International on 0499 920 848.

Job Reference ID (pick from dropdown) *

Title, first name, middle name(s), last name and postnominals should be as per your driver licence or, if you do not have a driver licence, your passport. Unless indicated otherwise, the name on your submitted proof of identity will be used for formal documentation.

First Name *

Middle name(s)

Surname *

Postnominals (Australian Honours List only)

All previous and other names known by (these names are used to undertake probity checks and will not be published).

Preferred title and name. (This is the title and name you will be appointed as if successful, it must match the title and name on your CV). *

Date of birth *

Place of birth (city/town) *

Country of birth *

Email address *

Mobile *

Residential address *

Street address *

City *

State *

Postcode *

Postal address (if different)

Street address

City

State

Postcode

Your answers to the questions below will not automatically include or exclude you from selection unless there is a corresponding legislative basis. It is important you refer to the expression of interest for the role you are applying for as you may be required to provide additional documents in relation to your answers in this section.

Are you a public sector employee? Note: The Remuneration Procedures for Part-time Chairs and Members of Queensland Government Bodies defines ‘Public sector employees’ as employees of federal, state or local governments, employees of semi-government organisations, either federal or state, including statutory authorities and employees of state and local government owned corporations and colleges. For the purpose of these procedures members of any parliament within Australia, elected local government representatives, judges, magistrates and other judicial and quasi-judicial officers are also regarded as public sector employees. Paid officials or employees of universities or Primary Health Networks are not included in this category. *

NoYes, please provide the following information:

Name of department or agency

Current role

Name of Chief Executive

Chief Executive email address

Are you an individual who owns a licensed pharmacy business in Queensland? *

NoYes - please provide the name of the pharmacy business

Name of business:

Are you a director of a corporation that owns a licensed pharmacy business in Queensland? *

NoYes - please provide the following information:

Corporation name

Pharmacy business name

Are you a practising pharmacist who is an employee of a licensed pharmacy business in Queensland? *

NoYes - please provide the following information:

Your Australian Health Practitioner Regulation Authority (AHPRA) registration number/s:

Pharmacy business name:

Do you have qualifications or experience in one or more of the following areas?

Primary Expertise (You may indicate more than one) *

AccountingBusinessFinancial managementLawGovernance and/or regulatory practiceCarrying on a pharmacy businessAnother area that: (a) qualifies you to represent consumers of pharmacy services: or (b) is appropriate or beneficial to the performance of the council’s functions.

Please provide details – you may attach a separate page or relevant supporting information:

Please attach any additional supporting information here:

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Diversity information (optional)

Deidentified data may be provided to relevant authorised officers to support the Queensland Government’s commitment to developing strategies and programs to promote diversity and inclusion on Queensland Government boards, committees and other government bodies.

Gender

FemaleMaleNon-binaryI do not wish to answer this question

Aboriginal and/or Torres Strait Islander people

Aboriginal people and Torres Strait Islander people are the First Peoples of Australia. An Aboriginal and/or Torres Strait Islander person is a person who is of Aboriginal and/or Torres Strait Islander descent and who identifies as such and is accepted as such by the Aboriginal and/or Torres Strait Islander people in the community in which they live or have lived.

Are you an Aboriginal and/or Torres Strait Islander person?

Yes, I am an Aboriginal personYes, I am a Torres Strait Islander personYes, I am both an Aboriginal and Torres Strait Islander personNo, I am not an Aboriginal or Torres Strait Islander person I do not wish to answer this question

Australian South Sea Islander people

Australian South Sea Islander people are the direct descendants of South Sea Islanders brought to Australia between 1863 and 1904 to work as indentured labourers.

Are you an Australian South Sea Islander person?

Yes, I am an Australian South Sea Islander personNo, I am not an Australian South Sea Islander person I do not wish to answer this question

Disability

A disability is a limitation, restriction or impairment which has lasted, or is likely to last, for a least six months and restricts everyday activities. There are many kinds of disability, usually resulting from accidents, illness or genetic disorders, and may include:

Physical
Sensory
Intellectual
Mental illness
Neurological

Do you identify as a person with a disability?

Yes, I identify as having a disability/disabilities No, I do not identify as having a disabilityI do not wish to answer this question

Culturally and Linguistically Diverse people

A Culturally and Linguistically Diverse person is a person who identifies as all or any of the following:

born overseas, including English-speaking countries
identify with a different cultural background other than Australian, including identifying with more than one culture e.g. Chinese–Australian
speak a language at home besides English (including Aboriginal and Torres Strait Islander languages).

In which country were you born?

Born in Australia Born overseas in a mainly English–speaking country, including but not limited to, New Zealand, United Kingdom, Ireland, Canada, United States of America and South AfricaBorn overseas in a mainly non-English speaking countryI do not wish to answer this question

Do you speak a language other than English at home? This includes Aboriginal or Torres Strait Islander languages.

YesNoI do not wish to answer this question

LGBTIQ+

LGBTIQ+ is an acronym describing people of diverse sexual orientations, gender identities and sex characteristics, short for lesbian, gay, bi-sexual, transgender, intersex and queer. The + reflects that the letters of the acronym do not capture the entire spectrum of sexual orientations, gender identities and intersex variations, and is not intended to be limiting or exclusive of certain groups.

Do you identify as an LGBTIQ+ person?

YesNoDon't knowI do not wish to answer this question

Documents

Which role are you applying for? *

MemberDeputy ChairpersonBoth

Attach Covering Letter *

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Member (maximum 2 page cover letter) / Deputy Chair (maximum 3 page cover letter)

Attach Resume *

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Maximum 2 page resume

Other (please specify)

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