* All mandatory fields must be completed.If you are unsure about the questions please reach us at heritageofficer@liverpool.nsw.gov.au.

PART 1:  PERSONAL DETAILS

Title	Family Name
Given Name	Date of Birth
Residential Address
Contact Details
Email Address

PART 2: MEMBERSHIP CRITERIA

Do you have any qualifications or work experience relevant to the subject committee? Please provide supporting information. *

Please provide supporting document:

Do you have an extensive knowledge of local history and local heritage? *

Please provide supporting information

Do you have experience in promoting and protecting heritage in Liverpool

What is your understanding of the role of Local Government within the management of Heritage?

Do you have a strong association with the residents and heritage community of the Liverpool Local Government Area? Please provide

Ownership of a heritage item within the Local Government Area

An ability to develop and sustain contacts with key individuals and groups in the local community

The ability to effectively listen, cooperate and function as a constructive member of a team

PART 3:OTHER

Are you a member of the indigenous community?

• Yes
• No

If yes, please specify

Are you a member of a historical society or heritage special interest group within the Liverpool Local Government Area?

• Yes
• No

If yes, please specify which group

* Agreement to the Terms and Conditions

• I have reviewed the charter of the Liverpool Built and Cultural Heritage Advisory Committee and accept the obligations and requirements within the Charter.
• I have reviewed the Liverpool City Council Code of Conduct. I acknowledge that if endorsed as a member of the committee, I am required to abide by the Code of Conduct, and I accept the requirements and provisions of the Code of Conduct.
• I have reviewed the Liverpool City Council Code of Meeting Practice. I acknowledge that if endorsed as a member of the committee, I am required to abide by the Code, and I accept the requirements and provisions of the Code.