APPLICATION FOR ENDORSEMENT

State of Victoria

When completing this application you can save your progress and return at any time to submit it.

"*" indicates required fields

Step 1 of 13 - Electorate

House of Parliament - Electorate

Please indicate which house of parliament you are applying to be candidate for*

Legislative Assembly

Legislative Council

Electorate for which endorsement is sought*

Electorate Information

Name*

First Middle Last

Residential Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Electoral Role Address*

Same as my 'Residential Address' listed above.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Untick this box to enter your address as it appears on the Electoral Roll.

Date of birth (optional)

MM slash DD slash YYYY

Place and country of birth*

Years of residence in Australia*

Years of residence in Victoria*

Police Check*

I agree to provide a police check within 2 weeks on being advised my application has been approved.

I understand that candidates selected to stand for election must provide a police check within 2 weeks on being advised their application has been approved, but must be provided prior to the candidate being officially nominated by the party.

Accompanying statement

Please state your reasons for seeking candidature*

Details of political activities

Have you ever been a member of any political party other than the Companions and Pets Party?*

Yes

Provide details...*

Have you ever participated as an elected representative or stood as a candidate for local government?*

Yes

Provide details...*

Have you represented any political party other than the Companions and Pets Party as either a scrutineer, distributor of political material or as a candidate, or have you ever provided financial assistance to another political party?*

Yes

Provide details...*

Have you ever been a member of any politically active group(s)?*

Yes

Provide details...*

Please provide information that demonstrates your ability to effectively assist the party as a candidate.*

Consider the following areas:

your major areas of policy interest and expertise
major political objectives
Skills/attributes you believe you can offer
raising funds for campaign expenses
responding to the issues raised by competing political parties/agendas

Education Details

Institution

Years Attended

Qualification

Education & Professional Qualifications

Employment Details

Company

Address

Job Title

Duties

Employment To

MM slash DD slash YYYY

Employment From

MM slash DD slash YYYY

May we contact this employer for a reference?

Yes

Employment history

Organisation Involvement

Outline your participation as a member and/or director of public companies, private companies, family trusts, not for profit organisation or community group*

Enter N/A if not applicable.

Organisation

Activities

Position Held

Involved From

MM slash DD slash YYYY

Involved To

MM slash DD slash YYYY

Community Involvement

Online and social media

Please list any websites you have or have had, including those you have been an administrator of. Outline the purpose of the website, and any blogging you have been involved in.*

Enter N/A if not applicable.

Additional information

Do you hold, or have previously held or been entitled to citizenship of another country?*

Yes

Do you hold, or have ever held any office under the Australian, a state or territory government?*

Yes

Do you hold, or have ever held a position with any government authority or agency?*

Yes

Are you currently employed by any of the above?*

Yes

Further information

While the Companion and Pets Party respects the privacy and judgement of potential candidates, there are some matters relating to the personal and financial affairs of candidates that do require disclosure to the Nomination Committee.

Please give careful consideration as to whether there are any issues that may adversely impact on your candidature and/or may inadvertently undermine the ability of the Companions and Pets Party to run a professional and well-coordinated campaign in your seat and across Victoria.

Answering in the affirmative to any of the questions below does not prevent anyone from being considered as a candidate.

If you respond in the affirmative to any of the matters below then you must disclose them to the Nomination Committee.

All information and details of discussions will be confidential unless you agree that they be released by the State Director.

Do not make any disclosure in writing on this application, however you are required to separately disclose the relevant information if you:

Have a criminal record
Have ever had a Violent Restraining Order (VRO) taken out against you
Have been involved in any civil proceedings that would embarrass the Party
Owe monies to the Australian Taxation Office (ATO)
Have ever been a bankrupt
Have debts that may be difficult to service or are owed to lenders that may embarrass the party
Are a director of a public company, private company, family trust, not for profit organisation or community group
Have ever been or are involved in a company that is or has been insolvent, in receivership, in the process of being wound up
Have ever been involved in a company that, or as an individual, been under investigation by the ASIC, ACCC, CCC or ATO
Have ever been, or the company, or other officers of the company you have been involved in have been prosecuted under the Corporation Law
Details of complaints and subsequent investigations into your affairs by the Trade Practices Commission or the Department of Commerce
Have been involved in any unfair dismissal cases as either an employer or employee
Have been a candidate for Local Government or a Local Government member / representative (this information may include the funding and disclosure of campaign expenses and policy positions taken that may conflict with policies of the Companion and Pets Party)

You are also asked to consider issues such as (but not limited to):

Criminal Charges
Civil offences (e.g., drink driving, assault, loss of driving licence, sexual harassment, traffic infringements, etc.)
Issues surrounding alcohol or illicit drugs
Matters concerning Taxation, ASIC, Law Enforcement agencies etc.

You are not prevented from being considered as a candidate should you have any experiences or exposure to the issues identified above.

Consent*

I acknowledge that as part of the Selection Committee process, in the presence of delegates to the Selection Committee, I will be asked:*

“Do you know of anything in your past or present that if it were made public could be damaging to or affect the reputation of the Companion and Pets Party?”

Consent*

In the event that there are any issues that may adversely impact on your candidature and/or may inadvertently undermine the ability of the Companions and Pets Party to run a professional and well-coordinated campaign in your seat and across Victoria, you agree to discuss these matters with the Nomination Committee and make further disclosure if required.*

All details of discussions will be strictly confidential unless you agree otherwise.

Declaration statements

GENERAL

I have read and satisfy the statutory qualifications for election as a member of Parliament.
All particulars supplied in this application and declaration are true and correct.
I agree to abide by the constitution of the Companions and Pets Party.
If I should be endorsed and then at any time in the future fail to regain endorsement, or decide not to seek endorsement, I will not stand as a candidate for any seat in any election without the consent of the Companions and Pets Party. I also understand that in signing the Application for Endorsement I have acknowledged my support for the principles, platform and policies of the Companions and Pets Party.
If I should not be endorsed, or if at any time in the future fail to gain endorsement, or decide not to seek endorsement, I will not stand for any election in any seat without the consent of the Companions and Party.
I hereby give authority to the Companions and Pets Party, that should I stand as a candidate for any seat in any election without the authority of the Companions and Pets Party, then the Companions and Pets Party has my consent to distribute a copy of this agreement to the media.

FINANCE AND COMPLIANCE

All campaign monies and funds will be raised in the name of the Companions and Pets Party and will be placed in the Companions and Pets Party Bank Account, bearing the name of the Companions and Pets Party. No withdrawals from this account will be made without approval by the Registered Officer of the Party.
The campaign bank account, campaign funds and money will be under the control of the Registered Officer. The Registered Officer will determine the Authorities on the campaign bank account and will appoint the signatories to operate the account.
I undertake to comply with the directions of the Registered Officer of the Party to diligently and expeditiously prepare and supply to the Registered Officer all financial accountability statements as are required under the Acts and other legislation.
I am aware of the donation rules and disclosures required under the Victorian Electoral Act and will comply with the act at all times, and any other financial and fundraising rules and guidelines set by the Companions and Pets Party.
I agree to be personally responsible for any expenditure incurred by me without the prior express authority of the Registered Officer and I further agree to indemnify the Companions and Pets Party against any liability arising from such unauthorised expenditure made by myself or those nominated by me to manage the finances of my campaign.
I agree to accept full responsibility for any statements made or authorised by me in my campaign and I further agree to indemnify the Companions and Pets Party against all actions, claims, damages, and costs arising from any such statements made by me in my campaign.

CAMPAIGN AND PERFORMANCE

I understand that the Registered Officer is the person legally and organisationally responsible for running the election campaign and will follow all instructions and rulings given to me by the Registered Officer.
I agree to attend candidate training when required by the Party.
I undertake to provide the Party, on a monthly basis or more frequently as may be required by the Registered Officer, a detailed performance assessment and any other relevant details as required by the Party.
I understand that all information and materials made available to me are to remain confidential to the Companions and Pets Party.
I understand that as an endorsed candidate, and if elected to Parliament, I will take part in and co-operate with regular performance reviews with the Registered Officer.
In the event of two or more candidates (including myself) being endorsed by the Party for a seat, I or will ensure all election material will clearly urge voters to give their preference vote to the other candidate/s.
I agree to provide all administrator access to all existing and future social media and website activity to the Registered Officer and will not commence any new such activity without specific approval from the Registered Officer.
I agree that I will, if requested by the Registered Officer redirect any existing domain names to a website nominated by the Registered Officer.
I understand that as an endorsed candidate, and if elected to Parliament, I will not conduct or commission any opinion polling or similar research without the consent of the Registered Officer.
The Registered Officer of the Companions and Pets Party is responsible for the secure storage of this agreement and related documents.

Consent*

I have read and understood the declaration statements above.*

Signature*

Signatures

By signing this Application for Endorsement Form, I certify that the above information is true and correct, and I understand and acknowledge that any false information, failure to disclose relevant information or failure to abide by the undertakings may result in financial and reputational loss to the Companions and Pets Party and the applicant shall reimburse the Companions and Pets Party for any and all losses resulting from this breach.

I understand that false or misleading information in my application or interview may result in my dis-endorsement and removal from the Party.

The Applicant*

First Middle Last

Signature*

Date

MM slash DD slash YYYY

The Witness*

First Middle Last

Witness' Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code