Online Request for a Consumer Representative

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Breast Cancer Action Group NSW
Online Request for a Consumer Representative Form

The Breast Cancer Action Group NSW provides a voice for all people affected by breast cancer and we thank you for asking us to help assist your organisation in recruiting consumer representatives for your specific needs. To help us select the best representative for you please complete this request form in as much detail as possible.

Application Lodgement Date:

Number of Representatives Requested:

A. Requesting Organisation Details

Name of organisation

Name and position of contact person

Postal Address

Suburb

City

State

Postcode

Phone (day)

(evening)

(mobile)

Fax

Website

B. Requested Consumer Representation Details

Representation Type Please tick the appropriate box or complete the OTHER section

Working group		Review panel
Focus group		Guideline development panel
Committee		Other (please specify)

Other

Name of Working group/Focus group/Committee/Panel or Other

Project description/Terms of reference (in layperson's terms please)

Experience or interests required from consumer representative(s)

Proposed commitment required from consumer representative

Duration of each meeting

Meeting frequency

Times of meetings

Evening

Weekends

First/next meeting date

Meeting location

Available assistance for consumer representative
We expect travel expenses and other related costs to be met by your organisation. Please confirm your organisation's policy on assistance.

C. Completed forms

	Press this button once after completing the form. This will send the information you have typed in the boxes above to us by email.
	Click this button to clear all information from the form (use this only if you want to start again)

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