Knox Community Safety Advisory Committee

Community Representative Nomination Form

Personal details

Last Name / First
Street Address
Suburb / Postcode
Phone (BH) / Phone (Mobile)
Email Address
Gender
Cultural Background
Aboriginal or Torres Strait Islander
Do you have any dietary requirements?
If yes, please provide details / YES NO

APPLICATION DETAILS

Are you a resident of Knox who has an interest in and a working knowledge of identified community safety priorities? / YES NO
Where did you hear about the opening of nominations for this Committee?
The Leader Newspaper
Knox Website
Facebook
Twitter
Friends/family/work colleagues
Council’s Customer Service advertisement
Council’s Community Strengthening e-bulletin
Other
What is your age group?
under 18 years
18 – 34 years 50 – 64 years
35 – 49 years 65 +

experience

Have you had experience being a member of a Committee or other leadership role in a community organisation?
If Yes, briefly describe your experience?
Why do you wish to be a member of this Committee? / YES NO

skills and knowledge

Council is interested in the knowledge and skills you believe that you can contribute to the functioning and effectiveness of the Knox Community Safety Advisory Committee.
  1. What is your specific area of expertise, interest and/or understanding of the Community Safety priorities as written in the Knox Community Safety Plan 2013-2017?

  1. What is your understanding of a prevention approach and its influence on crime and safety?

  1. How do you think you can contribute to enabling collaborative community partnerships to support the implementation of actions in the Knox Community Safety Plan?

  1. What other skills and/or knowledge would you bring to the committee (for example administration, project management, leadership, public relations)?

AVAILABILITY

Are you available to attend bi-monthly meetings at the Knox Council Civic Centre on Thursday mornings? / YES NO

REFEREE

Please provide details of your nominated referee to support your application.
Name
Address
Postcode
Organisation
Phone (BH) / Phone (Mobile)
Email Address

Signature

I certify that my answers are true and complete to the best of my knowledge.
Signature / Date
The personal information requested is being collected by Council for the Knox Community
Safety Advisory Committee and will be used solely by Council for the primary purpose or directly related purposes. The applicant understands that the personal information provided is for the above purpose and that he or she may apply to Council for access to and/or amendments of the information. Requests for access and or correction should be made to Knox City Council Privacy Officer

Please return your application by5PM ON MONDAY 13 MARCH 2017 to:

Lisette Pine, Coordinator Community Safety and Development
Knox City Council, 511 Burwood Highway, Wantirna South VIC 3152
Phone 9298 8000
Email
KCSAC Community Representative Nomination Form February 2017 / 1