Expression of interest for Inner West Air Quality Community Reference Group

If you would like to apply to participate in the Inner West Air Quality Community Reference Group please complete the questions below.

Yes, but I will need access to child care

I would like more information

Air quality monitoring, inventories and similar

Emerging air quality challenges

General air quality in my community

Government air quality policy

Industry emissions

Motor vehicles or transport emissions

Planned burns

Wood heating

Other (please specify)

I am of Aboriginal or Torres Strait Islander descent

I was born overseas

I am Australian born with one or both parents born overseas

I have children (one or more)

I mainly speak a language other than English at home

I live in social or public housing

I have a disability and/or accessibility requirement

None of the above

Other (please specify)

I am aged 12 to 17 years old

I am aged 18 to 24 years old

I am aged 25 to 34 years old

I am aged 35 to 49 years old

I am aged 50 to 59 years old

I am aged 60 to 69 years old

I am aged 70 to 84 years old

I am aged 85 years old or over

Expression of interest for Inner West Air Quality Community Reference Group

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* 2. The Inner West Air Quality Community Reference Group will focus on a number of different air quality issues. Please indicate what air quality issues in the inner west you have an interest in or are passionate about:

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* 3. The Government intends for the Inner West Air Quality Community Reference Group to be gender balanced. Please indicate the gender you identify with (if applicable):

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* 4. The Government intends for the Inner West Air Quality Community Reference Group to represent a cross-section of the inner west community. Could you please indicate if you identify with any of the following statements:

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* 5. If you selected any of the statements in Question 4 please briefly provide some additional relevant information:

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* 6. Where possible, the Government intends for the Inner West Air Quality Community Reference Group to consist of age cohorts based on demographic proportions in the inner west. Could you please indicate which of the following statements apply to you:

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* 7. The Government intends for the Inner West Air Quality Community Reference Group to consist of members who live within the Brimbank, Maribyrnong and Hobsons Bay local government areas. Please indicate what suburb you live in:

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* 8. Please indicate your street name (optional):

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* 9. Please provide a short explanation of why you want to be a member of the Inner West Air Quality Reference Group:

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* 10. Please provide a short explanation of the expertise or experience you have, if any, that you might bring as a member of the Inner West Air Quality Community Reference Group (e.g. participation in school councils, landcare):

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* 11. Name

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* 12. Job title (if applicable)

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* 13. Organisation (if applicable)

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* 14. Email

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* 15. Phone number