Disciplinary Panel appointments - Nomination Form
Please complete this form as fully as you can. If you have any questions, please contact the Sport
Integrity Commission Te Kahu Raunui at
[email address]
Privacy statement
The information you provide wil be used to assess your suitability for appointment as a Disciplinary
Panel member. If you do not provide all information requested in this form, we may be unable to process
your nomination. Your information wil be held by the Commission and wil only be shared if permitted
or required by law. You have the right to ask for a copy of any personal information we hold about you,
and to ask for it to be corrected if you think it is wrong by contacting
[email address].
Required information
You need to provide four parts to your application
You must provide
four parts to your application:
1. a completed and signed version of this form;
2. a copy of your photo ID, either
passport OR
New Zealand driver’s licence;
3. a cover letter explaining how your skil s and experience meet the selection criteria; and
4. a full current version of your curriculum vitae (CV).
Nominee
Personal details
Surname
First name
Preferred name
Daytime telephone number
Postal address
Email address
Gender
Male, female, gender diverse or prefer not
to say
41-50
51-60
Age
<30 years
31-40
years
years
years
60+ years Prefer not
to say
(Please tick the relevant box)
☐
☐
☐
☐
☐
☐
New Zealand Citizenship or
Immigration Status
(Please provide a copy of the front page
of your passport/ proof of your visa status)
2
Ethnicities
(and iwi affiliation if applicable
)
Current and most recent
employment
(Specify position and employer, including
tenure - support with a current CV)
Professional and tertiary qualifications (For example, Bachelor of Commerce, Master of Commerce)
Qualification
Institution
Year awarded
Professional memberships (For example, Institute of Directors in New Zealand, New Zealand Institute
of Chartered Accountants, Archives and Records Association of New Zealand)
Body
Member since
Government-appointed board or tribunal experience
Body
Position
Start date
Finish date
Other board or tribunal experience Body
Position
Start date
Finish date
Disciplinary Panel appointments - Nomination Form
3
Paid and voluntary work experience Organisation
Position
Start date
Finish date
Referees Please provide the names of two referees whose consent has been obtained and who may be
contacted for a confidential reference. (Ideally a current or former chair or manager)
Name
Company /
organisation
Relationship to you
Phone
Email
Name
Company /
organisation
Relationship to you
Phone
Email
Health Matters Do you have, or have you ever had, a medical condition caused by an injury,
Yes / No
il ness, disability or any gradual process that may be aggravated by, or affect
your ability to carry out the tasks expected of a member of a body?
If YES, please provide
details:
(Type / write here)
If you have responded
YES, what
(Type / write here)
accommodation,
facilities or equipment
would you require to
be able to perform the
role?
Disciplinary Panel appointments - Nomination Form
4
Possible conflicts of interest Do you have any professional associations, community links, investments or family
connections with the body? If so, please list.
For example, if the nomination is for a funding body and you or a close family member serves on a charity
that seeks funding from that body, then you would need to list that
Criminal record A criminal conviction wil not necessarily exclude you from being considered for appointment. Any
previous convictions that meet the criteria of the Criminal Records (Clean Slate) Act 2004 do not
need to be disclosed. For information on the Act, see https://www.justice.govt.nz/criminal-
records/clean-slate/
The Commission may decide to check your record for criminal convictions and/or
your credit status.
Do you consent to such a check?
Yes / No
If you have answered
(Type / write here)
NO to the above
question, please provide
details:
Have you ever been convicted of any offence in New Zealand or in any other
Yes / No
country (other than minor traffic or parking offences)?
Are there any charges against you yet to be heard?
Yes / No
If you have answered
(Type / write here)
YES to either or both of
the above two questions,
please provide details:
Please indicate below where you found out about this role?
Disciplinary Panel appointments - Nomination Form
5
Disclosures
Have you been the subject of any disciplinary action by a professional body in
Yes / No
New Zealand or overseas?
Have you been made bankrupt, entered into a composition with creditors, or been
Yes / No
disqualified as a director?
Are there any other probity issues or other issues the Minister would need to be
Yes / No
informed of before considering recommending you to the position you are
applying for.?
If you have answered
YES to any of the above questions, please provide details below:
Declaration:
I,
(full legal name)
confirm that the information I have given in this form is complete, true and correct.
I consent to the Commission:
• verifying, at any time, the accuracy of the information I have provided in this disclosure form and
my application materials;
• making enquiries with government agencies/entities and other relevant bodies to confirm
background information and assess my candidacy;
• if appointed, releasing a CV summary and contact details to the Registrar of the Disciplinary
Panel to assist with induction and administrative arrangements.
I confirm that:
• I have read the candidate information sheet detailing the nature of the role, the time commitment
and the remuneration.
If I am appointed:
• I agree to promptly declare any actual or potential conflict of interest or probity issue to the Chair
who wil decide how the conflict or probity issue can best be managed. I also agree to abide by
any decisions about the management of that conflict or probity issue. I acknowledge that, in the
event that a conflict or probity issue cannot be managed, that the Board of the Commission may
reconsider the suitability of me continuing to be a member of the Disciplinary Panel.
Signature:
Date:
Disciplinary Panel appointments - Nomination Form
Document Outline
