Application Form for appointment to Queensland Pharmacy Business Ownership Council

Please complete all the questions as they apply to you in the following application form and click submit. If you haven’t completed a mandatory field it will prompt you to complete the question before you can submit the form.

    Personal Details

    These details 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.
    (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 These names are used to undertake probity checks and will not be published.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.
    (if outside of Australia, please select Overseas)

    Residential Address

    (number and street name)

    Postal Address

    YesNo, my postal address is:

    Employment

    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.
    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
    NoYes, please provide the name of the pharmacy business
    NoYes, please provide the following information
    NoYes, please provide the following information
    Your Australian Health Practitioner Regulation Authority (AHPRA) registration number(s):
    AccountingBusinessFinancial managementLawCarrying on a pharmacy businessAnother area that: qualifies you to represent consumers of pharmacy services: or is appropriate or beneficial to the performance of the council's functions.
    ChairpersonDeputy ChairpersonMember

    Please provide details of two referees:

    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.
    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.
    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 personI 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.
    Yes, I am an Australian South Sea Islander personNo, I am not an Australian South Sea Islander personI 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

    Yes, I identify as having a disability/disabilitiesNo, 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).

    Born in AustraliaBorn 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
    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.

    YesNoI don't knowI do not wish to answer this question
    Yes