<p>Aboriginal Cultural Heritage Management 3-Day Workshop Nomination Form Nominee Details: (Please complete a Nomination Form for EACH person nominated from your organisation. Feel free to nominate more than one representative for each workshop). </p><p>Name______Date of Birth: _____/______/______Postal Address:______Telephone & Mobile:______</p><p>Email: ______Fax: ______</p><p>Workshop Preference: Circle one Ngootyoong Mara 18-20 July 2017 or LA Trobe Uni 22-24 August 2017 (Portland) (IAS Bundoora Campus) (closing date for applications 5/7/2017) (closing date for applications 9/8/2017)</p><p>Organisation Details: </p><p>Are you employed by a RAP organisation? (circle one) Yes No RAP or RAP Applicant Name: ______Postal Address: ______Telephone & Mobile: ______Email:______Fax:______</p><p>Are you employed by a non-RAP organisation? (circle one) Yes No Community/ Government Organisation Name:______Postal Address: ______Telephone & Mobile:______Email:______Fax:______What is the primary function of your organisation (eg education, land management)? ______</p><p>Your Position in the Organisation: (circle one) Cultural Officer Treasurer Site Monitor Director/Chairperson Public Officer Secretary Board Member Other Staff (specify)______</p><p>Are you: (circle one) Full time Part time Casual Volunteer</p><p>1 of 5 Educational Experience: </p><p>What level of schooling have you completed? (circle one) Less than Year 10 Year 10 Year 11 Year 12 </p><p>Post secondary qualifications: (circle one or more and provide the course name) Certificate II _____ Certificate III Certificate IV Diploma Degree </p><p>Are you Aboriginal and/or Torres Strait Islander? YES NO (circle one) If YES which traditional group do you belong to? ______Nominee Background: Please provide a written paragraph discussing in your own words your experience and/or goals in Cultural Heritage Management, for example:  What skills or knowledge do you bring to this workshop and  What do you hope to gain by participating.</p><p>2 of 5 Joint Learning Agreement: Aboriginal Victoria agrees to provide: • High quality training in a positive learning environment • Relevant course materials, readings and resources • Participant support for accommodation, meals and specific travel. </p><p>I (print your name)______agree to: • Attend all sessions of the ACHM workshop , from 9:00 am to 4:30 pm each day for three days • Fully participate in the workshop in a professional, positive and respectful manner. Personal Declaration: I have read the agreement and will fulfil the obligations to the best of my ability. I understand that full attendance and participation in the Introductory ACHM workshop is required to gain entry in the Certificate IV in Aboriginal Cultural Heritage Management course. Failing to observe this agreement or any inappropriate behaviour during the course may result in a withdrawal of AV sponsorship support under the ACHMT program. </p><p>Signature: Signature : </p><p>(Course Participant) (Aboriginal Victoria Representative)</p><p>Date:______/_____/______Date:______/_____/______OR Organisational Declaration: If you are participating on behalf of a RAP or as a staff member of another organisation please ensure the Chairperson/CEO of your board signs the declaration below: </p><p>I , endorse the nomination of (print name of chairperson) (print name of nominee) to participate in the Aboriginal Cultural Heritage Management three-day workshop. </p><p>Signed:______(signature of Chairperson/CEO) Date:______/_____/______Accommodation:</p><p>Will you require accommodation during the workshop? (circle one) No Yes </p><p>If yes, will you be arriving the night before? (circle one) No Yes </p><p>Do you have any special dietary, health or access issues? _</p><p>(please specify) </p><p>3 of 5 Send this nomination form to: Christina Pavlides - Manager, ACHMTP Aboriginal Victoria, Department of Premier and Cabinet Level 3, 1 Treasury Place, Melbourne Vic 3000 OR Email: [email protected] OR Fax: (03) 8080 3226</p><p>More information Contact: Chris Pavlides on [email protected] OR (03) 9208 3279 OR 0419 353 804 Successful nominees will be notified by telephone and/or writing one week prior to the workshops.</p><p>4 of 5</p>