Puka Tautapa Mema Komiti Tohatoha ā-Rohe
Local Distribution Committee Member Nomination Form
Released
To stand for the 2019 Local Distribution Committee (LDC) elections, nominees must complete the
form below. Nominees must provide information about their nominating organisation, a digital
photo and sign the declaration.
The completed nomination form must be emailed to the local office of the Department of Internal
Affairs or [email address] by
30 August 2019.
For support in completing this form, please refer to information o
n www.communitymatters.govt.nz.
Alternatively, you can speak to a local COGS advisor by phoning 0800 824 824.
under
Ngā here māraurau mō ngā kaitono mema LDC / Eligibility requirements of LDC member
candidates
All LDC member candidates must:
the
live or work in the area covered by the LDC
be over the age of 18 at the time of nomination
be eligible to remain in New Zealand, e.g. they are a New Zealand citizen or permanent resident,
Official
or hold a visa enabling them to remain in New Zealand for the period of their appointment
not be currently bankrupt or subject to a property order under the Protection of Personal and
Property Rights Act 1988
not be convicted of an offence punishable by imprisonment. Note: people who have served or
otherwise completed a sentence are eligible
Information
not be a permanently appointed staff member of the Department of Internal Affairs
not be a current LDC member completing a second consecutive three-year term.
Ngā here māraurau mō tētahi whakahaere tautapa / Eligibility requirements of a
nominating organisation
To be eligible to support a nomination, a community organisation must have been eligible to request
funding from the 2019 COGS funding round.
Act 1982
2019 LDC Election Nomination form
Mōhiohio tautapa / Nominee information
Ingoa tapa/First name:
Ingoa whānau/Family name:
Ingoa pai rawa/Preferred name:
Released
Wāhi whai reta/Mailing address:
Nama waea whakapā/Contact phone number:
Wāhitau īmēra/Email address:
under the Official Information Act 1982
E whai ana kia mema o tēhea LDC/LDC seeking membership of:
E whai ana kia mema o tēhea wāhanga (mēnā e hāngai ana)/Ward seeking membership of (if
applicable):
Mōhiohio whakahaere tautapa / Nominating organisation information
All nominations must be supported by an eligible community organisation. Provide the details of the
nominating organisation below.
Ingoa o te whakahaere tautapa/Nominating organisation name:
Tangata whakapā/Contact person:
Nama waea whakapā/Contact phone number:
Wāhitau īmēra/Email address:
2019 LDC Election Nomination form
Ngā mātauranga, pūkenga me ngā wheako o te tautapa / Nominee knowledge, skills and
experience
Please state the knowledge, skills and experience you have to offer the LDC
within one page.
Ingoa/Name:
Released
1. Provide a brief self-introduction. You are welcome to include a pepeha.
2. What experience, skills and knowledge do you have working or volunteering within your
under the Official Information Act 1982
community?
3. What experience, skills and knowledge do you have as a member of a committee or board?
4. What community leadership experience, skills and knowledge do you have?
5. What experience, skills and knowledge do you have in relation to different ethnicities and
sectors of the community. This could include: Māori, Pacific, other ethnicities, people with a
disability, rurally isolated people, youth, children and families, and elderly.
6. Add any further information that you want to be considered for your nomination.
Please provide a recent electronic photo of yourself.
2019 LDC Election Nomination form
Tauākī / Declaration
I acknowledge that if I am elected and then become ineligible according to the criteria, I will
cease to be an LDC member
I have read the duties and responsibilities of LDC members on the Community Matters website
Released
and undertake to fulfil them if elected
There is nothing in my financial or personal history that may bring the operation of COGS or the
activities of the LDC into disrepute
I acknowledge that if I am elected and it is subsequently discovered, at any time, that I have
made a false statement in this declaration, the process to remove me as an LDC member will
commence
I approve of the distribution of the information I have provided in the nomination form, to
under the Official Information Act 1982
community organisations for the purposes of 2019 LDC elections
I consent to my nomination.
Whakaū tautapa / Nomination confirmation
Tick the boxes to confirm your nomination.
I have attached an electronic photo with my nomination
I confirm I meet the eligibility requirements of an LDC member
I agree to the declaration.
Kua hainatia/Signed:
Te rā/Date:
2019 LDC Election Nomination form
