Australian Government - Australian Maritime Safety Authority
TECHNICAL ADVISORY PANEL NOMINATION FORM – AMSA 895
 
A. Personal details
Title (Mr, Mrs, Dr, etc.)
Surname
Given names
Street name and number
Town/suburb
State
Postcode
Country
Phone
Mobile
Email
B. Qualifications

Year
Title
Institution
D. Current position (Please submit a separate list or CV if there is insufficient space provided)
Year
Title
Institution
E. Areas of expertise (Please submit a separate list or CV if there is insufficient space provided)
F. Principal area(s) of interest (In relation to marine safety standards - eg operations, surveying, design, manufacture)

Please select either the parent category or the specific subsections applicable to your area of expertise.


Signature
Name

Please use a BLACK pen and ensure your signature fits inside the signature box

Date
Privacy Statement
The information requested in this form is being collected for the purpose of AMSA establishing technical advisory panels to assist it in carrying out its functions under the Navigation Act 2012 (Cth) and the Marine Safety (Domestic Commercial Vessel) National Law Act 2012 (Cth). The information provided will not be used or disclosed for another purpose unless the individual from whom it was collected has consented to that use or disclosure or its use or disclosure is otherwise authorised by law. To contact us, or for more information on how to access or correct your personal information, how to make a privacy complaint, or how your information may be used or disclosed for purposes beyond those described in this statement, visit www.amsa.gov.au/privacy.
How to lodge

You can email or post your application form to AMSA.

Email applications can be sent to consultation@amsa.gov.au

AMSA form: 895
Version: 1 7/18