Northland Health Consumer Council Expression of Interest – Te Whatu Ora

PERSONAL DETAILS

Name

First

Last

Postal Address

Address Address Line 2 City Postal Code Country

Email

Phone

ORGANISATION DETAILS [if nominated by an organisation]

Organisation Name

Nominator Name

First

Last

Nominator Role

Nominators Email

Nominators Phone

PROFILE

Why are you interested in being on the Consumer Council?

What consumer experience would you bring to the Consumer Council?

PERSONAL STATEMENT

Tell us a little about yourself.

Background

Community Involvement

Particular Health Interests

Work Experience

Other Information

DECLARATION

Note: All successful candidates will be required to undergo a New Zealand Police clearance. This clearance is subject to the Criminal Records (Clean Slate) Act 2004. For more information on the exception contained in Section 19(3)(3) of the Criminal Records (Clean Slate) Act 2004 please visit http://www.legislation.govt.nz.

Have you ever been convicted of a criminal offence?

Yes

No

VOLUNTEER CONSUMER

Please indicate if you are happy for your name to remain on our list of volunteer consumers to be contacted to participate in future Consumer Councils, other consumer groups or activities such as consumer workshops or patient experience interviews.

Yes

No

YOU WILL BE ASKED TO SIGN YOUR APPLICATION IF INTERVIEWED

I declare that to the best of my knowledge the answers provided in this expression of interest and any other information provided to Northland Health Consumer Council in support of my nomination is correct and I understand that if any false or deliberate misleading information is given, or any material suppressed, I will not be accepted.