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* 1. Name

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* 2. Address

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* 3. Email

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* 4. Phone

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* 5. Mobile

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* 6. Which Community Advisory Council region do you live or work in?

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* 7. Which position/s on the Clinical Advisory Council are you applying for?

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* 8. Do you identify as Aboriginal and/or Torres Strait Islander?

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* 9. Do you have knowledge and experience in Indigenous health?

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* 10. Keeping in mind the key selection criteria, please tell us why you are interested in joining the Clinical Advisory Council
(Please keep your answers to under 500 words)

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* 11. Please describe the value that you would add to the Clinical Advisory Council in terms of specific knowledge, skills and experience
(Please keep your answers to under 500 words)

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* 12. Would you like to be considered for the role of advisory council chair?

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* 13. Which of the seven Commonwealth priority areas for PHNs do you have skills within?
(Tick as many as are relevant)

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* 14. Please provide the names and contact details for two referees willing to provide information on your skills and experience.

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* 15. Please attach your CV or resume

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