Aboriginal Facilitator EOI application form - Individual

Please note, when completing the online form your progress will not be saved if you close the window or refresh the page. We recommend completing the application in one session.

Section A1 - Applicant details for individual

Name

Mobile phone

Section B - Assessment criteria

Section C - Additional information

If you are the successful applicant is there anything you would need from COORDINARE to help, make this a safe and meaningful experience for you and the community? If yes, please make a note below.

Section D - Declaration

This must be completed by the individual submitting the application:

If this application is successful, I am committed to participate in the project within the designated time frame.

If this application is successful, I agree to provide required payment document (including invoice and paid participation form) to COORDINARE – South Eastern NSW PHN.

I understand and accept that information provided in this application may be stored by COORDINARE – South Eastern NSW PHN in various hardcopy and/or electronic formats.

I understand that this application does not create a legal or binding commitment and that if successful I will be bound by a contract with COORDINARE - South Eastern NSW PHN.

I understand that I am required to have current and adequate insurances in place. (e.g., Professional indemnity insurance)

I can confirm that the contents of this application are to the best of my knowledge accurate, complete and do not contain any false, misleading or deceptive misrepresentation, claims or statements.

I understand that if the conditions of the funding are not complied with, COORDINARE – South Eastern NSW PHN may seek to recover any funds allocated.

Note: If you submit your application via video, it’s understood that you have read and accepted the above under Section D. Declaration.

Applicant signature

Full name

Date