PANEL OF ADVISORS

							                                                                                 Attachment A


                                  PANEL MEMBER PROFILE
PLEASE PRINT CLEARLY

NOTE that the giving of false or misleading information to the Commonwealth is a serious offence.

State

Name
Salutation                 Surname                                 First Name

Location Address (Please include post code)




Postal Address (Please include post code)




Contact Details (Please include area code)
Work phone
Home phone
Mobile
E-mail

Eligibility Category (please tick the appropriate boxes)
Adviser:
           Nurse/Clinical Adviser

           Business Financial Adviser

           Other–Indicate area of expertise:__________________________________________________

           Administrator

           Medical Practitioner


Conflict of Interest (please initial)
              Conflict of Interest (Attachment B completed and signed)
              I confirm that I am not a Commonwealth employee.

Release of information (Please tick one)
I agree to have my personal profile released to peak aged care bodies:     Yes       No




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Qualifications




Experience – (Please summarise your work experience – no more than 10 lines)




Area of Expertise – (Please summarise specialised skills/knowledge – no more than 8 lines)




                                                     Page 2 of 3
Referee Details (Please include two referees)

Referee 1
Name
Classification/Position
Address


Work phone
Mobile
E-mail address
Nature/Period of relationship

Referee 2
Name
Classification/Position
Address


Work phone
Mobile
E-mail address
Nature/Period of relationship




                                                Page 3 of 3