Application Form for CEO, Queensland Pharmacy Business Ownership Council

This form is to be used for individuals applying for the position of Chief Executive Officer, Queensland Pharmacy Business Ownership Council. The information is sought to assist in assessing your eligibility and suitability for nomination and/or appointment.

Your personal information will be treated as confidential and will only be used or accessed by authorised persons for the 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 Executive Quarter) 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.

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 – Managing Partner, 0499 920 848, [email protected] or Jason Hunt – Partner, 0432 388 910, [email protected]

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.

If you need some assistance with completing this form, please reach out to Tracy Robbins on [email protected] or call 0424 765 978.

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.

Title

First name

Middle name(s)

Last name

Postnominals (Australian Honours List Only)

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 These names are used to undertake probity checks and will not be published.

Preferred title and name 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

State or territory of birth* (if outside of Australia, please select Overseas)

Phone number(s)

Residential Address

Street address (number and street name)

Suburb (or city/town)

State or territory*

Postcode

Country

Postal Address

Is your residential address the same as your mailing address?*

YesNo, my postal address is:

Street address or PO Box

Suburb (or city/town)

State or territory

Postcode

Country

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.

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

HealthcareBusinessManagementLaw

Please provide details

Please provide details of two referees:

Referee 1 Name

Referee 1 Organisation

Referee 1 Position

Referee 1 Phone

Referee 1 Email

Referee 1 Professional Relationship to applicant

Referee 2 Name

Referee 2 Organisation

Referee 2 Position

Referee 2 Phone

Referee 2 Email

Referee 2 Professional Relationship to applicant

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 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.

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 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

Do you identify with the above?

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).

In which country were you born?

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

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?

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

Where did you hear about this role?*

We are collecting your personal information to facilitate this recruitment process. Your information will be shared with the relevant parties involved in the recruitment process. We take measures to safeguard your data from unauthorised access. By providing your information, you consent to its collection, use, and sharing as described. You have the right to access and correct your data by contacting us at any time.

Yes