Capricorn S 2017 Director Elections Victoria/Tasmania Zone

CAPRICORN’S 2017 DIRECTOR ELECTIONS
VICTORIA/TASMANIA ZONE

NOMINATION FORM

IMPORTANT INFORMATION ABOUT COMPLETING THIS NOMINATION FORM

Please complete this Nomination Form in its entirety. Do not leave any sections or questions blank.

This Nomination Form must be properly completed and returned to Capricorn with the required accompanying documents by no later than:

(a)  19 June 2017 if you want to take part in the Capricorn Candidate Assessment Process (see section 2 below); or

(b)  14 July 2017 if you do not want to take part in the Capricorn Candidate Assessment Process.

Late or incorrectly completed Nomination Forms or Nomination Forms that are not accompanied by all required supporting documents will not be accepted.

Section 1: Nominee Details

Name of Nominee:
(full name of the individual seeking to be a candidate)
Date of Birth:
/ //
Member Name:
(name of the Capricorn member you are associated with (if a company or partnership) or your trading name (if you are a sole trader)
Capricorn Membership Number:
Industry Experience and Qualifications:
(provide details of your automotive and allied industry experience and qualifications relevant to your nomination) /
Board and Executive Committee Experience:
(provide details of any experience you have had on Boards or Committees that is relevant to your nomination) /
Education
(provide details of any formal education qualifications that are relevant to your nomination) /
Automotive Purchases
(For the Member listed above, what is the value of average monthly purchases of all automotive parts & accessories (not just those placed on your Capricorn Account) based on the last 24 months?) / $
Are either you or the Member listed above a member of any other automotive industry buying groups, co-operatives or any other organisation which represents a possible conflict of interest? / Yes / No
If you answered “yes” please list the relevant groups, co-operatives, bodies or other organisations below:

Section 2: Capricorn Candidate Assessment Process

Important: Due to the steps involved in the Capricorn Candidate Assessment Process, if you agree to take part you need to submit your Nomination Form and accompanying documents so that they are received by Capricorn by no later than 19 June 2017.

Participation in the Capricorn Candidate Assessment Process is voluntary. While it may help you better understand what is required in being a Director and help Members better assess your abilities as a potential Director, participation is not required. A decision not to participate in the Capricorn Candidate Assessment Process does not affect your eligibility to stand as a candidate. Voting Members will be informed as to which Candidates agreed and did not agree to submit to the Candidate Assessment Process.

Do you agree to take part in the Capricorn Candidate Assessment Process?* / Yes / No

* By ticking or affirming “yes” above to participating in the Capricorn Candidate Assessment Process then, in the event you receive a rating from such process and then proceed with your nomination, you will also be consenting to Capricorn disclosing your rating to Capricorn Members in the Victoria/Tasmania zone. If you do not consent to publication of your individual rating from the Candidate Assessment Process then you must clearly communicate the same in writing to the Capricorn Company Secretary prior to the Returning Officer causing to send the election Ballot Papers.

Section 3: Supporting Nominations

Important: Your nomination must be supported by two Capricorn Members that are recorded by Capricorn as being in the Victoria/Tasmania zone.

By completing and returning this Nomination Form you consent to Capricorn contacting and discussing by any means with the Members listed below your personal information and any other information whatsoever necessary or desirable for Capricorn to consider and determine your suitability and eligibility as a candidate in Capricorn’s 2017 Director Elections.

First Supporting Member

Name of Supporting Member:
Capricorn Membership Number:

We, the undersigned hereby nominate the person named in section 1 of this Nomination Form for the position of Capricorn Society Limited Director:

______
Signature of First Supporting Member / ______
Print Name
/ /
Date

Second Supporting Member

Name of Supporting Member:
Capricorn Membership Number:

We, the undersigned hereby nominate the person named in section 1 of this Nomination Form for the position of Capricorn Society Limited Director:

______
Signature of Second Supporting Member / ______
Print Name
/ /
Date

Section 4: References

Important: Please provide details of up to three people who can be contacted in support of this nomination. These people do not have to be Capricorn Members.

By completing and returning this Nomination Form you consent to Capricorn contacting and discussing with the referees listed below by any means your personal information and any other information whatsoever necessary or desirable for Capricorn to consider and determine your suitability and eligibility as a candidate in Capricorn’s 2017 Director Elections.

First Reference

Name of Referee:
Occupation:
Name of Employer or Business:
Postal Address:
/
Phone Number:
Email Address:

Second Reference

Name of Referee:
Occupation:
Name of Employer or Business:
Postal Address:
/
Phone Number:
Email Address:

Third Reference

Name of Referee:
Occupation:
Name of Employer or Business:
Postal Address:
/
Phone Number:
Email Address:

Section 5: Nominee’s Consent and Agreement

In accepting nomination for the position of Director of Capricorn Society Limited (“Capricorn”), I hereby agree and consent to the following:

Provision of Documents

a)  I have provided this Nomination Form, duly completed and supporting statutory declaration to Capricorn marked “CONFIDENTIAL” and addressed to:

Capricorn Company Secretary

Locked Bag 3003

West Perth, WA 6872

so that it is received no later than 19 June 2017 if I have agreed to take part in the Capricorn Candidate Assessment Process or, if otherwise, by no later than 14 July 2017, failing which my nomination will be invalid and not considered.

b)  A National Police Check Certificate obtained from the Police in my State/Territory dated no earlier than 14 May 2017 is either attached to this Nomination Form or will otherwise be provided to Capricorn by no later than 14 July 2017, failing which my nomination will be invalid and not considered without approval of the Capricorn Board (for Victorian candidates see www.police.vic.gov.au or for Tasmanian candidates see www.police.tas.gov.au for the required forms and further information on obtaining a National Police Check).

c)  A recent photograph (taken within the last six months) and a two page résumé in the approved template (as attached hereto) about myself which must be returned with this Nomination Form (if I have agreed to take part in the Capricorn Candidate Assessment Process) or is otherwise be provided to Capricorn by no later than 14 July 2017, failing which my nomination will be invalid and not considered without approval of the Capricorn Board;

d)  To providing a duly sworn or declared statutory declaration in the form provided by Capricorn which, in part, verifies that the statements of fact contained in this Nomination Form and accompanying documentation are true and correct according to my knowledge, information and belief. To providing such Statutory Declaration by attaching the same to this Nomination Form.

Consents

e)  Capricorn’s Company Secretary or the Returning Officer to Capricorn’s 2017 Director Elections may shorten my final résumé accompanying the ballot papers in their absolute and unfettered discretion if it is longer than two pages.

f)  Capricorn may provide a copy of my photograph, my final résumé and my rating from the Capricorn Candidate Assessment Process (if any) to all Capricorn Members eligible to vote in Capricorn’s 2017 Director Elections.

g)  If requested by Capricorn, I will provide financial statements which Capricorn considers necessary or desirable to verify the dollar value of my total monthly average purchases in automotive parts and accessories as provided in the Nomination Form.

h)  Capricorn can obtain a credit report on me (it being an eligibility requirement that the report be considered satisfactory by Capricorn).

Ongoing Obligations during Capricorn’s 2017 Director Elections and if Elected as a Director

i)  I will not canvass for votes and agree that I will be disqualified as a candidate in Capricorn’s 2017 Director Elections if it is proved to the Returning Officer’s satisfaction that I have canvassed for votes.

j)  I will notify the Capricorn Company Secretary or Returning Officer or, if elected as a Director, the Chair of the Board, if any of the statements contained in the statutory declaration provided with this Nomination Form change or no longer are true and correct according to my knowledge, information and belief.

k)  If elected as a Director I will attend all Capricorn Board and Board Committee Meetings as required unless excused by the Board for good reason.

l)  If elected as a Director I will resign if:

·  any of the information I provide in respect of my nomination as a candidate in Capricorn’s 2017 Director Elections can be considered misleading or deceptive by any reasonable person including but not limited to by statement and/or omission;

·  Directors determine that I no longer meet all the Standing Requirements in Clause 15.9 of the Capricorn Constitution; and/or

·  I become a “disqualified person” as understood by reference to the accompanying statutory declaration or if I no longer meet Capricorn’s Fit and Proper Person policy;

m)  If elected, to act as a Director of Capricorn and to be bound by, comply with and obey Capricorn’s Constitution, Board Charter, Fit and Proper Person Policy and also the code of conduct set by the Capricorn Board of Directors failing which I agree to resign as a Director;

n)  If elected, I undertake to attain graduate status of the Company Directors Diploma Course run by the Australian Institute of Company Directors (AICD) as soon as possible and by no later than 12 months from appointment or such later period (if any) as approved by the remainder of the Capricorn Board failing which I acknowledge that I am unlikely to be considered suitable for re-election for a further term.

Pre signing checklist:

● Are all sections of the Nomination Form completed?

● Have you attached the completed Statutory Declaration?

● Have you attached a recent photograph and two-page résumé in the approved format?

● Have you read and understood each of the items contained in section 5 that you are required to consent and agree to?

Documents to accompany this Nomination Form and to be received by Capricorn no later than 19 June 2017 (if participating in the Candidate Assessment Process) or 14 July 2017 (if not participating in the Candidate Assessment Process):

● Statutory Declaration

● Recent Photograph

● Two-page résumé in approved format

● National Police Check Certificate (only due by 14 July 2017 whether participating in the CAP or not)

Return Nomination Form and accompanying documents to Capricorn, marked “confidential”, at:

Capricorn Company Secretary

Locked Bag 3003

West Perth, WA 6872

Signature of Nominee / Print Name
//
Date
Your Name Here / Insert Photo Here
Date of Birth: dd/mm/yyyy
Opening remarks to be inserted here

Standard of Education:

·  List details of any memberships to institutions, Certificates, Diploma, Training Courses, endorsements etc which you may have obtained, the year obtained and with what institution.

Automotive Industry Experience Background:

·  Provide details

Relevant Board or Committee previous experience:

·  Please outline your position (i.e. Chairman, member etc), the organisation and duration of your experience.

Other relevant personal development:

·  Provide details

Community Involvement:

Over past years I have been involved in several voluntary community organisations such as:-

·  Please outline your position (i.e. Chairman, member etc), the organisation and duration of your experience, for example: Australian Volunteer Coast Guard – Division Vice Captain and Radio Commander

Declaration of membership or support of opposition Automotive Industry Buying Groups or Co-operatives:

·  I (insert ‘do not’) belong to any other opposition buying group or co-operative.

·  I (insert ‘do’) belong to other opposition buying group(s) or co-operative(s), the details of which are as follows:-

o 

I DECLARE that my commitment to Capricorn Society is demonstrated by the level of automotive parts and accessories purchasing of my business through Capricorn which is %

I DECLARE that I have no interest in any commercial or wholesale business supplying the Automotive Trade in Australia or New Zealand.

Other Content:

·  Provide details

Final Word

Insert your text here

*I can be contacted at work on or by mobile of or by email

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