PREQUALIFICATION SCHEME: AUDIT AND RISK COMMITTEE INDEPENDENT CHAIRS AND MEMBERS

APPLICATION FORM

SubmissionThis form is to be completed by all applicants to the Prequalification Scheme: Audit and Risk Committee Independent Chairs and Members. All questions are mandatory unless otherwise stated. Please be brief but ensure that you provide all relevant details to assist the Assessment Committee arrive at a determination.

Please email the completed application, as either a word or PDF document to: auditriskmembers@finance.nsw.gov.au

Please note that hand written applications cannot be accepted.

A) APPLICANT DETAILS

Name

Residential Address

Postal Address

Phone

Mobile

Web (Optional) - Insert website or Linkedin profile

Email

Current Employer and ABN

Do you have any specific requests or requirements to be considered by the Assessment Committee? For example, are you requesting prequalification for a specific Audit & Risk Committee or Committees?

Application Type Prequalification as Member only

Prequalification as Member and Chair

Removal of limitation or upgrade of existing Prequalification from Member to Chair

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AREAS OF EXPERIENCEPlease indicate all areas in which you can demonstrate significant expertise.

B) POLICY EXPERIENCEAgeing and Disability

Housing

Arts Justice

Central Government – Policy, Legislation, Public Administration

Primary Industry

Community Services Public Employment/Workplace Relations

Economic Services Sport and Recreation

Education Taxation

Emergency Services Transport

Environment Utilities/Telecommunications

Health

FUNCTIONAL EXPERIENCE

Risk Management

Information and Communications Technology HR

Finance

Insurance

Internal Audit

External Audit

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C) APPLICANT RESUME

Please attach an up-to-date resume as a separate document. This should not exceed 5 pages. A cover letter or statement of intent is not required. However, you may include a cover letter provided it does not exceed 1 page. Please use default margins and font size.

D) CAPABILITY

You will be assessed against each of the criteria listed below. For each criterion, please provide a maximum of one page of information which demonstrates your ability to meet the required capability.

All applicants must complete Part A: Audit and Risk Committee Member. If applying for prequalification as a Chairperson, please also complete Part B: Audit and Risk Committee Chair.

Part A: Audit and Risk Committee Member (to be completed by all applicants)

1) Extensive senior level experience in governance and management of complex organisations, an ability to read and understand financial statements and a capacity to understand the ethical requirements of government (including potential conflicts of interest).

(Please answer in 1 page or less)

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2) Functional knowledge in areas such as: risk management; performance management; human resources management; internal and external auditing; financial reporting; accounting; management control frameworks; financial internal controls; governance (including planning, reporting and oversight); or business operations.

(Please answer in 1 page or less)

3) A capacity to form independent judgements and willingness to constructively challenge/question management practices and information.

(Please answer in 1 page or less)

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4) A professional, ethical approach to the exercise of duties; and the capacity to devote the necessary time and effort to the responsibilities of a Member of an Audit and Risk Management Committee.

(Please answer in 1 page or less)

5) Possession of a relevant professional qualification or membership is desirable (e.g. Certified Internal Auditor, Certified Practicing Accountant, Certified Practicing Risk Manager, Chartered Accountant, Member of the Australian Institute of Company Directors (MAICD).

(Please answer in 1 page or less)

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Part B. Audit and Risk Committee ChairIf applying for prequalification as an Audit and Risk Committee Chair, please complete Section B: Audit and Risk Committee Chair.

1. Leadership qualities and the ability to promote effective working relationships in complex organisations.

(Please answer in 1 page or less)

2. An ability to communicate complex and sensitive assessments in a tactful manner to chief audit executives, senior management, board members and Ministers.

(Please answer in 1 page or less)

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3. A sound understanding of:

a) the principles of good organisational governance and capacity to understand public sector accountability, including financial reporting;

b) the business of government departments or statutory bodies and the environment in which they operate (or capacity to quickly gain such an understanding);

c) internal audit operations, including selection and review of chief audit executives; and

d) risk management principles.

(Please answer in 1 page or less)

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E) AUDIT AND RISK COMMITTEE EXPERIENCE

Please list all relevant Audit and Risk Committee roles, including any Audit and Risk Committees and sub-Committees within the NSW Public Sector.Organisation Name of Committee Role/Position Start Date End Date

Please add more rows, if required

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F) APPLICANT REFEREE REPORTS

Please insert the contact details of 2 relevant referees.

Referee 1Name

Organisation

Position

Phone

Mobile

Email

Referee 2Name

Organisation

Position

Phone

Mobile

Email

Applicant Referee ReportsThe provision of an Applicant Referee Report (please see next page) is not required. The Office of Finance and Services (OFS) and the Assessment Committee may request that your nominated referees provide either an oral or written reference (in the form attached) at a later stage. OFS will not notify you prior to contacting your nominated referees.

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Please insert CORPORATE LETTERHEAD of referee’s organisation HERE(if applicable)

APPLICANT REFEREE REPORT(to be submitted where requested)

This report may be used to assist in assessing the suitability of an Applicant for the Prequalification Scheme – Audit and Risk Committee Independent Chairs and

Members.

OFS or the Assessment Committee may contact the referee to verify or clarify aspects of this Report

Applicant NameOrganisation Name PhoneIn what context do you know the applicant (Briefly describe)

Date Commenced Date Completed

Referee ReportPlease provide comments on the applicant’s performance (maximum of 2 pages,

making reference, as appropriate, to the assessment criteria (listed on next page).

SignedSignature NameDate Position TitleTel Mob email

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Please find below the assessment criteria against which applicants will be assessed.

Assessment Criteria Part 1 (all applicants)

1a

Extensive senior level experience in governance and management of complex organisations, an ability to read and understand financial statements and a capacity to understand the ethical requirements of government (including potential conflicts of interest).

1b

Functional knowledge in areas such as: enterprise risk management; performance management; human resources management; internal and external auditing; management control frameworks; financial internal controls; governance (including planning, reporting and oversight); or business operations.

1c A capacity to form independent judgments and willingness to constructively challenge/question management practices and information.

1dA professional, ethical approach to the exercise of their duties and the capacity to devote the necessary time and effort to the responsibilities of a member of an Audit and Risk Committee.

1ePossession of a relevant professional qualification or membership (e.g. Certified Internal Auditor, Certified Practicing Accountant, Certified Practicing Risk Manager, Member of the Australian Institute of Company Directors (MAICD) is desirable.

Assessment Criteria Part 2 (only if applying for Chairperson)

2a Leadership qualities and the ability to promote effective working relationships in complex organisations.

2b An ability to communicate complex and sensitive assessments in a tactful manner to chief audit executives, senior management, board members and Ministers.

2c

A sound understanding of: the principles of good organisational governance and capacity to understand

public sector accountability; internal audit operations, including selection and review of chief audit

executives; and risk management principles.

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G) POTENTIAL CONFLICTS OF INTEREST

The following questions are designed to help you and NSW Government Agencies determine potential conflicts of interest.

a) Are you currently employed/engaged by any organisations (excluding appointments to NSW Government Boards and Committees)? Please detail the organisation name and position title.

Organisation Name Position Title

Please add additional rows as required

b) Have you (whether as an individual or employee), undertaken any fee for service engagements, contracts (including subcontracts) or been otherwise employed by a NSW Government entity in the last three (3) years (excluding appointments to NSW Government Boards and Committees). If so, please specify the agency/agencies, nature of engagement and dates.

Agency Name Nature of engagement Dates

Please add additional rows as required

c) Do you hold a significant beneficial interest in any privately held companies prequalified under any other NSW Government prequalification schemes, including the Performance and Management Services scheme? If so, please provide company name, ABN and describe nature of interest in company.

d) Please nominate any real or potential conflicts of interest.

Please note that OFS may inform NSW Government Agencies or other relevant parties of potential conflicts of interest.

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H) STATEMENT

The information that you provide in this application will be used for the purposes of assessing and processing your application. Information you disclose may also be used by OFS and Treasury to identify potential conflicts of interest and to facilitate the continued operation, administration and future enhancements to the Scheme.

All information provided to OFS may be stored in the Government Organisations Database (GODB), maintained by the Department of Premier and Cabinet. NSW Government Departments and Statutory Bodies will be provided with access to the GODB for the purposes of identifying potential candidates and making appointments to Audit and Risk Committees.

State Owned Corporations may, on special request, also be provided access to the GODB for the purpose of identifying potential candidates and making appointments to Audit and Risk Committees or Boards.

Applicants may request that their information be “Restricted” and only be made available to specific agencies.

I agree to disclose my personal information and CV to NSW Government Departments, Statutory Bodies and State Owned Corporations seeking to engage Independent Chairs or Members.

OR

Please tick

I only agree to disclose my personal information and CV to specified agencies for the purpose of being engaged as an Independent Chair or Member:

Please specify the agencies below:

I hereby confirm the completeness and authenticity of the information provided in this application and will act in accordance with the Scheme Conditions.

Signature of Applicant

Applicant Name

Date

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APPLICATION CHECKLISTPlease use the following checklist to ensure that your application is complete.

Item

Mandatory Criteria and Requirements Completed

A Applicant Details

B Experience

C Resume (attached as a separate document)

D.1 Applicant Capability - Part A (all applicants)

D.2 Applicant Capability – Part B (only if applying as Chairperson)

E Audit and Risk Committee Experience

F Contact details for 2 referees

G Potential conflict of interests

H Statement Submission:Please email the completed application to auditriskmembers@finance.nsw.gov.au

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