Expression of Interest - Quality Committee

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Expression of Interest - Quality Committee

Please fill in the below form to express your interest in joining the Quality Committee.

* Required

First Name *

Surname *

Number and Street Name *

Town / Suburb *

Postcode *

Home Phone Number

Work Phone Number

Mobile

E-mail *

Attach your Curriculum Vitae

What has motivated you to apply for a position on the DHSV Quality Committee?

Please outline your experience as a consumer of public oral health services.

What skills or knowledge would you bring to the role?

Do you have any experience on similar committees or with community groups? *

	Yes
	No

Please list any Committees / Groups you have been involved with along with Position and Period of Service

Can you commit to quarterly meetings of 2 - 2.5 hours for a term of up to three years? *

	Yes
	No

Do you have a current police name check? *

	Yes (please attach a scanned copy below)
	No

Police Name Check

If you are unable to attach a copy of your Police Name Check - please forward it to:

Megan Waddell
Executive Assistant
Dental Health Services Victoria
GPO Box 1273L
MELBOURNE VIC 3001

I wish to apply for a position on the DHSV Quality Committee. I understand that DHSV will collect and use my information on a confidential basis for the purposes described in this document.

I agree with the above statement

	Yes
	No

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