EIS Health Limited Board 2025: Expressions of Interest Form

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1 Uppercase letter
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Please use this form to submit an Expression of Interest in joining the EIS Health Limited Board.

I currently live or work in the area covered by CESPHN

Applicants must live or work in the area covered by CESPHN in order to be eligible

Contact Details

First Name

Middle Name(s)

Last Name

Preferred Name

Post Nom

Contact Number/Alternative

Email Address

Residential Address

Number and Street Name

Suburb

State

Postcode

Do you have a different postal address?

YesNo

Postal Address (if different)

Number and Street Name

Suburb

State

Postcode

Do you identify as a member of any of these groups?

Person with a disability/special needsAboriginal and/or Torres Straight Islander personCulturally and Linguistically Diverse (CALD)

Is there any further information you would like to provide (optional)?

Qualifications and Expertise

Please outline your formal qualifications (400 characters)

Please outline what interactions, if any, you have had or currently have with CESPHN (200 characters)

Please outline what interactions, if any, you have had or currently have with other PHNs (200 characters)

Do you have any affiliations with universities and/or research centres? If yes, please provide details.

Are you currently a member of any other boards or committees? If yes, please provide details.

Do you wish to be considered for other EIS Health committees or councils?

YesNo

Skills Sought

The CESPHN Board is seeking to ensure a well-rounded mix of expertise to support effective governance and strategic leadership. Please describe how your experience and expertise in any of the below areas would enable you to add value to the Board. (400 words)

Governance
Legal
Information technology
Commercial accumen

Please also outline any additional skills, knowledge, or perspectives you would bring that could enhance the Board’s effectiveness and diversity. (400 words)

Declaration

I understand a requirement of becoming a Director is to have, or be willing to obtain, a Director ID issued by the Australian government.

I agree with the above statement

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