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Please complete all sections of this form. It must be signed and dated.  

Attach a brief CV detailing your education and training, full employment history, specific skills and abilities and any other details that you feel will be useful to support your application.  

For more information about applications, click here.

Are you a New Zealand or Australian citizen?*
If you are not a New Zealand or Australian citizen: Do you have permanent residency in New Zealand; or Do you have a permit and/or visa to work in New Zealand?

You will be required to provide evidence of your citizenship, permanent residence or permit/visa if your application proceeds.  This will usually be your passport, or a New Zealand birth certificate or citizenship certificate and some form of photo identification such as a New Zealand driver’s licence. 

Are you physically located in New Zealand?*
Have you been convicted of any offence against the law within the last seven years or do you have any criminal charges pending (apart from minor speeding or parking offences)?

Note: a false declaration about prior convictions or pending prosecutions will invalidate your application. You may be required to agree to a Ministry of Justice check. 


Please provide the names and telephone numbers of anyone you would be happy for the Health Quality & Safety Commission to contact about your suitability to be a member of the National Mortality Review Committee. We require at least two referees.

Authority and declaration

I hereby authorise the Health Quality & Safety Commission to collect such personal information about me from the named referees as is necessary to assess my suitability for appointment to the National Mortality Review Committee and I authorise the Health Quality & Safety Commission to disclose such personal information as is necessary for the same purpose. I also authorise the named referees holding such information about me to disclose that information to the Health Quality & Safety Commission for the same purpose. 

I certify that the information provided is correct and no information has been omitted. 

By typing your name below, you are ‘electronically signing’ this form. A copy of your email and form will be kept for our records. 

Last updated: 27th March, 2023