B
oard/Committee
Member
Payment Instruction Form
Information collected on this form is used by Shared Services on behalf of ACT Public Service agencies. Information collected will only be used for the purpose for which you gave it and will not be disclosed to any person, body or directorate except where required by law.
Personal Details |
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Title: |
Family Name: |
Given Names: |
Date of Birth: / / |
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Residential Address:
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Postal Address (if different from residential):
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Phone 1: |
Phone 2: |
Email: |
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AGS or Employee Number (if known): |
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Bank Account Details (account where any remuneration can be paid into) |
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Bank/Credit Union: |
Account Name: |
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BSB Number: |
Account Number: |
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Mandatory Documents - Board/Committee Member Checklist |
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You must complete and return these documents to your directorate contact person with this form: |
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Superannuation Acknowledgement and Election forms |
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Tax File Number Declaration form Mandatory Evidentiary Documents – you must provide a certified true copy (i.e. original document sighted, copied and signed by a Justice of the Peace, Police Officer or a Public Servant with 5 years service) of the following documentation:
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Directorate Delegate to Complete |
Name of Board/Committee: |
Position Number: Note: If a position number has not been established your directorate must action an Establishment Variation Authority form |
Term of Appointment: / / to / / (specify dates) |
Annual Salary/Per Diem: (please specify $ amount) $ |
I certify that the Board/Committee member has been engaged in accordance with the ACTPS Boards and Committees Handbook (CMTEDD Office) and the ACT Remuneration Tribunal Classification Guidelines and Remuneration determination (www.cmd.act.gov.au/governance/remtrib/determinations): |
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Delegate Name: |
Title: |
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Signature: |
Date: / / |
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Directorate: |
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Directorate Contact Officer: |
Phone No: |
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To avoid delays with processing, please ensure directorate contact officer details are provided. |
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Shared Services Recruitment Officer to Complete |
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Mandatory documents completed |
Date: / / |
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AGS issued |
Signature: |
Forward Board/Committee Commencement Package to Shared Services:
Scan and email: [email protected]
Internal mail: HR Service Desk, GPO Box 158, Canberra ACT 2601
Version
2.0 Issued: 1/9/2014 Page
Tags: collected on, information collected, collected, oardcommittee, instruction, information, member, payment