Application for Endorsement

2025

Thank you for taking part in The Nationals WA preselection process. This online Application for Endorsement is the first step in your preselection journey.

The purpose of this application is to ensure that the Party has a thorough understanding of an applicant’s background in the event that they become a preselected candidate for the Party. This information will help ensure that any issues raised during an election campaign can be dealt with quickly.

There are questions within this application form which might ordinarily be regarded as invasive or may make you feel uncomfortable. Unfortunately, in modern politics, candidates for parliamentary election, and those successfully elected, have very limited rights to privacy in terms of their personal, professional or business backgrounds. The Nationals WA has a responsibility to maintain the integrity and reputation of the Party in the eyes of its members, supporters and the wider public.

Full and frank disclosure is fundamental to the application process, and any inaccuracy or omission in the answers you provide may result in your exclusion as a candidate for endorsement.

All information you provide within this application is only viewed by members of The Nationals WA Candidate Selection Committee.

All information you provide is strictly confidential.

Important Information

You can save and return to your application at any time, prior to submission.

If you select the "Save and Complete Later" function at the bottom of the page, it is imperative that you copy and save your unique URL that appears. To re-visit the application, paste your unique URL into the search bar.

Some of the questions you will be asked in this online application will be particular to the responses you give to other questions. Questions that are not relevant to you, based on the responses you provide to the required*questions, will not appear.

A non-refundable application fee of $2,750 applies. At the conclusion of this application, you will be asked to pay the non-refundable application fee using the online payment facility. The application will not be complete without payment.

As part of your application, you will be asked to upload a number of documents relating to your finances, employment, business interests, criminal and driver history, qualifications, and military and/or police service (if applicable). While it is recommended that you submit these documents via the online application, to ensure they are received, the application will allow you to progress and submit your application without uploading these documents. If you do not upload these documents as part of your online application, you will be required to submit them to info@nationalswa.com within 7 working days of the closing day for nominations.

Applicants who fail to provide these documents will forfeit their application and their non-refundable application fee.

Please be aware, the information provided in this application is treated in the strictest confidence and by stringent security standards. We will ensure that any information you provide is solely for the purposes of assessing your application. For more information, contact info@nationalswa.com.

If you subsequently apply for some other endorsement, we may take into account matters disclosed in the course of this application.

1. Preliminary Matters

Membership and Electorate

Are you a financial member of The Nationals WA? *

Yes No

To apply for preselection you must first become a member of The Nationals WA. To do this, follow this link ( here) or call The Nationals WA Secretariat on 1300 628 792.

If you would like to learn more about The Nationals WA's preselection process before becoming a member, please email your enquiry to info@nationalswa.com.au and include your full contact details.

For which electorate are you seeking endorsement? *

Please provide the details of two current paid members of That Nationals WA who nominate you for preselection.

Nominator 1

Nominator first name *

Nominator last name *

Nominator email address *

Nominator mobile *

Nominator local branch *

Nominator 2

Nominator 2 first name *

Nominator 2 last name *

Nominator 2 email address *

Nominator 2 mobile *

Nominator 2 local branch *

I confirm that I have contacted my nominators and that they are happy to vouch for me *

2. Applicant Particulars

Name Details

First Name *

Middle Name(s)

Last Name *

Are you, or have you been, known by any other name(s), including other surnames and any informal names by which you are publicly or professionally known (e.g. Mick for Michael, Kathy for Katherine) (but not including informal nicknames)? *

YesNo

What is/was the other name(s)? *

Date(s) of name change(s)/use(s) *

Reason(s) for name change(s)/use(s)

Birth Details

Date of Birth *

Hospital Name

City

State / Territory

Country *

What Country were you born in?

Citizenship

Are you an Australian citizen? *

YesNo

Do you hold, or are you entitled to hold, citizenship in another Country? *

YesNo

Which Country? Please provide any details.

Contact Details

Mobile Number *

Home Number

Email Address *

Do you have any other email accounts (including inactive accounts)? *

YesNo

Please list any additional email addresses and their purposes (e.g. personal, work, company, office bearer) *

Australian Addresses

Residential Address *

Street address *Street address line 2 *

City *

State *

Postcode *

Have you lived at this address for the past 10 years? *

YesNo

Please provide your previous residential addresses for the past 10 years (including the duration you were at each address)

Have you resided in any Australian State or Territory other than Western Australia? *

YesNo

Please list all States and/or Territories you have resided in at any time and the years you resided in each (including any periods more than 10 years ago)

Enrolment Information

Are you currently enrolled to vote? *

YesNo

Enrolment is an eligibility requirement to be elected to the Western Australian Parliament. Please contact info@nationalswa.com before proceeding further.

Are you currently living in the electorate for which you are seeking endorsement? *

YesNo

Is your electoral address the same as your residential address provided above? *

YesNo

Electoral Address *

Street address *Street address line 2 *

City *

State *

Postcode *

Are you currently a silent elector? *

YesNo

Please provide details as to why you are currently a silent elector

International Addresses and Travel

Have you resided in a Country other than Australia? *

YesNo

Please list all Countries you have resided in at any time, the years you resided in each, and the reasons for residing there (including any periods more than 10 years ago)

Have you visited any Countries other than Australia in the past 10 years (not including any Countries you resided in provided above)? *

YesNo

Please list all Countries you have visited in the past 10 years (but not resided in), including the month/year, length of stay, and reason for each visit (e.g. holiday, business trip, visiting family, political exchange)

3. Relationships

What is your marital status? *

What is the full name of your current spouse/partner? *

Please upload a copy of the Divorce Order/Certificate

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Prior to or following your separation from your spouse/partner, had you, or have you, commenced a new relationship? *

YesNo

What date did that relationship commence

Have you ever previously been married or lived in a de facto relationship? *

YesNo

Please provide details of the nature of the relationship, the name of your former spouse/partner, and the dates that the relationship commenced and ceased. If you have had more than one spouse and/or de facto partner, please provide these details for all relationships.

Have you ever applied for an order to protect yourself against family and domestic violence or abuse of any kind? *

YesNo

Against whom did you make the application (full name)?

On what date did you make the application?

What were the circumstances of the application?

What was the outcome of the application?

Has anyone ever applied for an order against you in which allegations were made that you engaged in family and domestic violence or abuse of any kind? *

YesNo

Who made the application (full name)?

On what date was the application made?

What were the circumstances of the application?

What was the outcome of the application?

Have you ever been a party to court proceedings arising from a family law dispute? *

Yes No

What is the full name of the other party?

Have the proceedings been finalised? *

YesNo

On what date were they finalised?

What were the circumstances of the proceedings?

What are the circumstances of the proceedings?

Has any court or government department ever ordered you to pay spousal maintenance? *

YesNo

On what date was the order made?

Please provide details of the order. If you are subject to more than one spousal maintenance order, please include details of all orders.

4. Children

Do you have any children (including any step-children)? *

YesNo

Please provide the names and dates of birth of any children you have, including from previous relationships, step-children, guardianships and adoptions.

Full Name (Child 1)

Date of Birth (Child 1)

Add a second child?

YesNo

Full Name (Child 2)

Date of Birth (Child 2)

Add a third child?

YesNo

Full Name (Child 3)

Date of Birth (Child 3)

Add a fourth child?

YesNo

Full Name (Child 4)

Date of Birth (Child 4)

Do you have any additional children to add?

YesNo

Please list the full name(s) and date(s) of birth for any additional children

Has anyone ever made a complaint that you have engaged in child abuse of any kind? *

YesNo

To the extent permitted by law, please provide details of the allegation, the date of the complaint and the outcome

To the extent permitted by law, please provide any documents relating to the allegation

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Have you ever been involved in court proceedings relating to the custody of a child? *

YesNo

To the extent permitted by law, please provide details, the date(s) of the proceedings and the outcome

To the extent permitted by law, please provide any documents relating to these proceedings, including any orders made by the court

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Has a court or government department ever ordered you to pay child maintenance? *

YesNo

To the extent permitted by law, please provide details and the date(s) of the order(s)

To the extent permitted by law, please provide any documents relating to these proceedings, including any orders made by the court

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5. Employment

Employment Documents

All applicants are required to attach a current CV ( maximum of four (4) pages) and head-shot photograph as part of their application. Your CV should outline your employment, education, qualifications, business activities, community involvement and referees.

Consistency of information

Prior to submitting your application, all applicants are to ensure that if an item is listed in your CV and also appears in any other publicly-available profiles (e.g. LinkedIn, Facebook), then the relevant details appear in a consistent manner in all places*. (i.e. details match for start and end dates, position titles, employer/community group names, qualification/award titles, organisation names and conferral dates.)

*This does not mean an applicant needs to add all jobs, businesses, qualifications, community positions, etc to their CV and all their profiles – only that if an item does appear in multiple places, the item’s details are consistent everywhere.

I have reviewed my CV and other publicly-available profiles (as applicable) to ensure the information provided in my CV is consistent to the extent any items are also listed across my other profiles. *

Employment Details

Are you currently employed? *

YesNo

Is your current employer aware you are completing this application? *

Yes No

Who is your employer, and what is your occupation title? Please include your employer's contact details for the purpose of a reference check.

Have you been with your current employer for three or more years? *

YesNo

Please provide your previous two employers' details, including the employers' names, positions held and the durations of your employment with each

Do you give consent to contact your current and/or previous employer(s) *

YesNo

Please provide details as to why you are not currently employed

Please provide your previous two employers' details, including the employers' names, positions held and the durations of your employment with each

Please upload your current CV (maximum of four (4) pages) and head-shot photograph *

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Workplace Conduct

Have you ever been dismissed or suspended from your employment, or asked to resign from your employment? *

YesNo

When and from where were you dismissed, suspended, or asked to resign? What was the reason? Did you seek any remediation, either internally or through the courts?

Have you ever been the subject of a complaint of workplace bullying, harassment, dishonesty, or sexual misconduct? *

YesNo

What were the particulars of the allegation? What investigation took place? (e.g. internal review, police referral, etc.) What was the outcome of the investigation?

Have you ever made a complaint of workplace bullying, harassment, dishonesty or sexual misconduct? *

YesNo

What were the particulars of the allegation? What investigation took place? (e.g. internal review, police referral, etc.) What was the outcome of the investigation?

Have you ever made a claim for unfair dismissal? *

YesNo

What were the particulars of the claim? Where and on what date(s) was the matter adjudicated? What was the outcome?

If you answered "Yes" to any question in this Workplace Conduct section, to the extent permitted by law, please upload any relevant documents

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To the extent permitted by law, and regardless of whether you were the complainant, subject or respondent in the matter.

6. Qualifications and Awards

Evidence of Qualifications and Awards

All applicants are required to provide a copy of, or supporting evidence for, any qualification, registration, award, citation, honour, medal or bursary disclosed in their application, their CV or in any other publicly-available profiles (e.g. LinkedIn, Facebook).

This can be in the form of the certificate(s), the academic transcript(s) or the letter(s) from the relevant institution(s). Documentary evidence must include your full name, the exact name of the qualification / registration / award / citation / honour / medal / bursary, the organisation that awarded/conferred it, and the date on which it was awarded/conferred.

Consistency of information

Prior to submitting your application, all applicants are to ensure that if a qualification or award is provided below and also appears in their CV and any other publicly-available profiles (e.g. LinkedIn, Facebook), then the relevant details appear in a consistent manner in all places*. (i.e. details match for qualification/award titles, organisation names and conferral dates).

*This does not mean an applicant needs to add all qualifications, awards, etc to their CV and all their profiles – only that if an item does appear in multiple places, the item’s details are consistent everywhere.

I have reviewed my CV and other publicly-available profiles (as applicable) to ensure the qualifications and awards information below is consistent to the extent any items are also listed in my CV and across my other profiles. *

Qualifications and Registrations

Please list your academic qualifications, if any (including the institution and year of completion/conferral)

Please list your professional, trade and business qualifications and/or registrations, if any (including the institution and year of completion/conferral/registration)

Please list any other qualifications, if any

Please upload documentary evidence for all qualifications or registrations provided above

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Awards and Honours

Please list any awards, citations, honours, medals or bursaries, if any (including the name of award/citation/honour/medal, institution/organisation and date awarded/conferred)

Please upload documentary evidence for all awards, citations, honours, medals or bursaries provided above

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7. Business

Information in public registers

Prior to submitting your application, all applicants are to ensure that any business and company information provided below is up-to-date and correctly reflected in any public ASIC, ATO, ACNC or other registers. (i.e. business names, company names, registered addresses, principal place of business addresses, your name, your address, your date of birth, your place of birth, your director/officer positions held, your private company shareholdings, ABN status, charity reporting obligations.)

I have reviewed the information provided below to ensure it is up-to-date and correctly reflected in any relevant public registers. *

Sole Proprietorships

Do you own or operate a business as a sole proprietor? *

YesNo

Under what name does the business operate? If more than one, please provide details for all business names.

What is the business's ABN? If more than one, please provide details for all businesses.

What is the nature of the business? Please describe its purpose, business activities and any major assets/liabilities. If more than one, please provide details for all businesses.

Partnerships

Do you own or operate a business through a partnership? *

YesNo

What is/are the name(s) of the other partner(s)? If more than one, please provide details for all partnerships.

Under what name does the business operate? If more than one, please provide details for all business names.

What is the business's ABN? If more than one, please provide details for all businesses.

What is the nature of the business? Please describe its purpose, business activities and any major assets/liabilities. If more than one, please provide details for all businesses.

Trusts

Do you own or operate a business through a trust? *

YesNo

What is the name of the trust? If more than one, please provide details for all trusts.

Who is/are the trustee(s) of the trust? If more than one, please provide details for all trustees of all trusts.

Who is/are the beneficiary/beneficiaries of the trust? If more than one, please provide details for all beneficiaries of all trusts.

Under what name does the business operate? If more than one, please provide details for all business names.

What is the business's ABN? If more than one, please provide details for all businesses.

What is the nature of the business? Please describe its purpose, business activities and any major assets/liabilities. If more than one, please provide details for all businesses.

Companies

Taxation Documents for Companies

All applicants who:

(a) own or operate a business through a company; and/or

(b) are a director of and/or shareholder in any other private compan y(including a private company involved in self-managed superannuation funds and trust structures)

are required to provide, for the five-year period immediately preceding this application, copies of:

the company income tax account; and
the income tax lodgement report; and
the integrated client (activity statement) account; and
the activity statement lodgement report

for all companies covered by paragraphs (a) and (b) above. These reports can be obtained by your tax agent through the ATO tax agent portal. Applicants should redact/black-out any tax file numbers included in their documents prior to uploading.

Directors

Are you a director of any private companies? *

YesNo

Are you a director of any public companies? *

YesNo

Please provide the following details for all of the private companies of which you are a director. (If any details are not applicable, please type "n/a".) If you are a director of more than one company, please add additional companies as required.

Director - Company 1

Registered Company Name (Company 1)

Trading Name (Company 1)

Registered Address (Company 1)

Principal Place of Business Address (Company 1)

ACN (Company 1)

ABN (Company 1)

What is the nature of Company 1's business? Please describe its purpose, business activities and any major assets/liabilities.

Please upload a copy of Company 1's "Current & Historical Organisation Extract" from ASIC

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Add a second director company?

YesNo

Director - Company 2

Registered Company Name (Company 2)

Trading Name (Company 2)

Registered Address (Company 2)

Principal Place of Business Address (Company 2)

ACN (Company 2)

ABN (Company 2)

What is the nature of Company 2's business? Please describe its purpose, business activities and any major assets/liabilities.

Please upload a copy of Company 2's "Current & Historical Organisation Extract" from ASIC

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Do you have any additional director companies to add?

YesNo

Director - Additional Companies

Please provide the following details for any additional companies of which you are a director: registered company name(s); trading name(s); registered address(es); principal place of business address(es); ACN(s); ABN(s); and details of the nature of the business(es)

Please upload a copy/copies of the "Current & Historical Organisation Extract" from ASIC for these additional companies

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Please provide the following details for all of the public companies of which you are a director. (If any details are not applicable, please type "n/a".) If you are a director of more than one company, please add additional companies as required.

Director - Company 1

Registered Company Name (Company 1)

Trading Name (Company 1)

Registered Address (Company 1)

Principal Place of Business Address (Company 1)

ACN (Company 1)

ABN (Company 1)

What is the nature of Company 1's business? Please describe its purpose, business activities and any major assets/liabilities.

Please upload a copy of Company 1's "Current & Historical Organisation Extract" from ASIC

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Add a second director company

YesNo

Director - Company 2

Registered Company Name (Company 2)

Trading Name (Company 2)

Registered Address (Company 2)

Principal Place of Business Address (Company 2)

ACN (Company 2)

ABN (Company 2)

What is the nature of Company 2's business? Please describe its purpose, business activities and any major assets/liabilities.

Please upload a copy of Company 2's "Current & Historical Organisation Extract" from ASIC

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Do you have any additional director companies to add?

YesNo

Director - Additional Companies

Please upload a copy/copies of the "Current & Historical Organisation Extract" from ASIC for these additional companies

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Officers

Are you a non-director officer (e.g. secretary) of any private and/or public companies of which you are not also a director?

YesNo

Please provide the following details for all of the private and public companies of which you are an officer, but not a director. (If any details are not applicable, please type "n/a".) If you are an officer of more than one company, please add additional companies as required.

Officer - Company 1

Registered Company Name (Company 1)

Trading Name (Company 1)

Registered Address (Company 1)

Principal Place of Business Address (Company 1)

ACN (Company 1)

ABN (Company 1)

What is the nature of Company 1's business? Please describe its purpose, business activities and any major assets/liabilities.

Please upload a copy of Company 1's "Current & Historical Organisation Extract" from ASIC

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Do you have any additional officer companies to add?

YesNo

Officer - Additional Companies

Please provide the following details for any additional companies of which you are an officer, but not a director: registered company name(s); trading name(s); registered address(es); principal place of business address(es); ACN(s); ABN(s); and details of the nature of the business(es)

Please upload a copy/copies of the "Current & Historical Organisation Extract" from ASIC for these additional companies

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Shareholders

Are you a shareholder (or beneficiary in any way) in any private companies of which you are not also a director or other officer? (Do not include being a shareholder in any public companies.) *

YesNo

Please provide the following details for all of the private companies only in which you are a shareholder, but not a director or other officer. (If any details are not applicable, please type "n/a".) If you are a shareholder in more than one company, please add additional companies as required.

Shareholder - Company 1

Registered Company Name (Company 1)

Trading Name (Company 1)

Registered Address (Company 1)

Principal Place of Business Address (Company 1)

ACN (Company 1)

ABN (Company 1)

What is the nature of Company 1's business? Please describe its purpose, business activities and any major assets/liabilities.

Please upload a copy of Company 1's "Current & Historical Organisation Extract" from ASIC

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Do you have any additional shareholder companies to add?

YesNo

Shareholder - Additional Companies

Please provide the following details for any additional private companies in which you are shareholder, but not a director or other officer: registered company name(s); trading name(s); registered address(es); principal place of business address(es); ACN(s); ABN(s); and details of the nature of the business(es)

Please upload a copy/copies of the "Current & Historical Organisation Extract" from ASIC for these additional companies

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Businesses through any other Companies

Do you own or operate a business through a company that has not already been disclosed above? *

YesNo

Please provide the following details for any other companies that have not already been disclosed above through which you own or operate a business: registered company name(s); trading name(s); registered address(es); principal place of business address(es); ACN(s); ABN(s); and details of the nature of the business(es)

Please upload a copy/copies of the "Current & Historical Organisation Extract" from ASIC for these additional companies

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Company Obligations and Conduct

Not including companies that have already been disclosed above, have you ever formerly been a director or other officer (whether of a private or public company), or a shareholder or other beneficiary (in a private company)? *

YesNo

Have companies for which you were formerly a director or other officer or shareholder ever been wound up due to insolvency or for any other reason? *

YesNo

Please provide details

Have any of the companies of which you are, or were, a director or other officer ever been the subject of an investigation of any kind, including but not limited to an investigation by a professional regulatory body, a trade association, ASIC, the ACCC, the ATO, the Fair Work Ombudsman, the Office of Fair Trading, any Police Service, Safe Work Australia, or any other federal, state or local government or government entity? *

YesNo

Please provide details

Has your conduct as a current or former director or other officer ever been the subject of an investigation of any kind, including but not limited to an investigation by a professional regulatory body, a trade association, ASIC, the ACCC, the ATO, the Fair Work Ombudsman, the Office of Fair Trading, any Police Service, Safe Work Australia or any other federal, state or local government or government entity? *

YesNo

Please provide details

Have you ever been involved in, while a director or otherwise, a complaint of workplace bullying, unfair dismissal, harassment, dishonesty, or sexual misconduct? *

YesNo

Please provide details

8. Finances

Personal Taxation Documents

All applicants are required to provide, for the two-year period immediately preceding this application, copies of:

their personal income tax notices of assessment; and
their personal income tax account; and
their personal income tax lodgement report; and
their personal integrated client (activity statement) account, if applicable; and
their personal activity statement lodgement report, if applicable.

If you do not have a tax agent, these documents can be obtained through the ATO Portal on your MyGov account. Applicants should redact/black-out any tax file numbers included in their documents prior to uploading.

If you are unable to, or prefer to not include your tax documents as part of this online form, please contact the State Director for alternative methods to provide these details. Pelase contact the State Director at statedirector@nationalswa.com

Expenses and Liabilities

What are your average total monthly expenses? *

Please provide details of your four largest lines of credit (e.g. mortgage, credit card, unsecured loan, secured loan, Afterpay/other buy-now-pay-later, etc), including the credit issuer, the outstanding balance and the credit limit. If you have fewer than four open lines of credit, please type "n/a" as applicable.

Largest line of credit 1

Largest line of credit 2

Largest line of credit 3

Largest line of credit 4

Do you have any debts of any kind that are outstanding beyond agreed terms? *

YesNo

Please provide details

Please provide copies of any relevant correspondence including invoices, demand notices, receipts and court documents

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Do you have any unpaid fines or penalties? *

YesNo

Please provide details

Please provide copies of any relevant correspondence including invoices, demand notices, receipts and court documents

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Do you have any gambling debts? *

YesNo

Please provide details

Please provide copies of any relevant correspondence including invoices, demand notices, receipts and court documents

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Have you ever had a debt referred to a collection agency? *

YesNo

Please provide details

Please provide copies of any relevant correspondence including invoices, demand notices, receipts and court documents

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Are you currently an undischarged bankrupt? *

YesNo

As an undischarged bankrupt, you are not eligible to be elected to the Western Australia Parliament. Please contact info@nationalswa.com before proceding with this application.

Have you previously been an undischarged bankrupt? *

Yes No

On what date was the bankruptcy or insolvency discharged?

Please provide details

If relevant, and to the extent permitted by law, please upload the bankruptcy discharge certificate

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Have you ever entered into an arrangement with creditors under the Bankruptcy Act? *

YesNo

Please provide details

To the extent permitted by law, please upload any copy of, or documents relating to, the arrangement

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Income and Assets

What is your average total monthly income (after-tax) from all sources?

Do you or any spouse/partner have any real estate interests not already disclosed elsewhere in this application (including your family home)? (e.g. residential, commercial, agricultural land) *

YesNo

Please provide details of real estate holdings (location and purpose)

Do you or any spouse/partner have any significant personal property interests not already disclosed elsewhere in this application (not including any ordinary motor vehicles used for day-to-day purposes)? (e.g. antique cars, boats or other watercraft, planes, collections of significant value) *

YesNo

Please provide details of significant personal property

Do you or any spouse/partner have interests in any publicly-listed shares or other securities not already disclosed elsewhere in this application? *

YesNo

Please provide details of the publicly-listed shares or other securities (name and code only)

Do you have any other interests in trusts (whether as a trustee or beneficiary) not already disclosed elsewhere in this application? *

YesNo

Please provide specific details of all other interests in trusts

Do you or any spouse/partner have any other foreign interests not already disclosed elsewhere in this application, including property ownership, commercial ventures and/or holding companies? *

YesNo

Please provide specific details of all other foreign interests

Please upload your personal taxation documents

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All applicants are required to provide, for the two-year period immediately preceding this application, copies of: 1. their personal income tax notices of assessment; and 2. their personal income tax account; and 3. their personal income tax lodgement report; and 4. their personal integrated client (activity statement) account, if applicable; and 5. their personal activity statement lodgement report, if applicable.

9. Community Involvement

Information in public registers

Prior to submitting your application, all applicants are to ensure that any information provided below for a community group or not-for-profit organisation (whether a company, an incorporated association, or any other structure) is up-to-date and correctly reflected in any public ASIC, ATO, ACNC, Office of Fair Trading or other registers. (i.e. company/association names, registered addresses, principal place of business addresses, your name, your address, your date of birth, your place of birth, your positions held, ABN status, charity reporting obligations, Fair Trading returns and committee documents.)

Community Organisation Positions

Have you ever been an officeholder or a member of a board, management committee or similar body of a community group or not-for-profit organisation (not including an organisation already disclosed elsewhere in this application)? *

YesNo

Please provide the following details for all of the organisations for which you have held an officeholder or a board or management committee role. (If any details are not applicable, please type "n/a".) If there is more than one organisation, please add additional organisations as required.

Organisation 1

Organisation 1 Name

Organisation 1 Structure (e.g. company, incorporated association)

Registered Address (Organisation 1)

Role(s) Held (Organisation 1)

Dates Active (Organisation 1)

What is the nature of Organisation 1? Please describe its purpose, activities, and any major supporters/sponsors/initiatives.

Add a second organisation?

YesNo

Organisation 2

Organisation 2 Name

Organisation 2 Structure (e.g. company, incorporated association)

Registered Address (Organisation 2)

Role(s) Held (Organisation 2)

Dates Active (Organisation 2)

What is the nature of Organisation 2? Please describe its purpose, activities, and any major supporters/sponsors/initiatives.

Do you have any additional organisations to add?

YesNo

Additional Organisations

Please provide the following details for any additional organisations: organisation name(s); organisation structure(s); registered address(es); role(s) held; dates active; and details of the nature of the organisation(s)

Organisation Obligations and Conduct

At all times during which you held an officeholder or a board or management committee role with a community organisation, was that organisation able to pay its debts as and when they fell due? *

YesNo

Please provide details

At any time during which you held an officeholder or a board or management committee role with a community organisation, was any allegation of impropriety, corruption, mismanagement or dishonesty directed at you or at members of the organisation's management? *

YesNo

What were the particulars of the allegation? What investigation took place? (e.g. internal review, police referral, etc.) What was the outcome of the investigation?

Community Groups

Not including groups already disclosed elsewhere in this application, please list any community groups or significant community activities that you have been a part of in the last ten years, including political and/or culturally and linguistically diverse groups

Please list any online forums, community groups or pages such as sports club pages, parenting groups, or neighbourhood-based groups that you are a member of, have contributed to, or commented on

Have you made any significant donations to a community group, religious organisation or another not-for-profit organisation or charity? *

YesNo

Please provide details

10. Military Service

Have you served in the Australian Defence Force? *

YesNo

On what date did you enlist in the Australian Defence Force?

In what capacity have you served in the Australian Defence Force? Please specify the branch(es) in which you have served, key dates, and any deployment(s).

Have you been discharged from the Australian Defence Force? *

YesNo

On what date were you discharged from the Australian Defence Force?

What was the reason for your discharge from the Australian Defence Force?

During your ADF service, have you ever been, or were you ever, the subject of a complaint or suggestion of alleged misconduct? *

YesNo

What were the particulars of the allegation? What investigation took place? What was the outcome of the investigation?

11. Police Service

Have you ever served in the Australian Federal Police, the Western Australia Police Service, or any other Police Service/Force in Australia? *

YesNo

On what date did you enlist with the Police?

Please detail the Police Service(s)/Force(s) in which you have served, in what branch(es) and capacities, and on what dates

Have you been discharged (including voluntarily) from the Police? *

YesNo

On what date were you officially discharged from the Police?

What was the reason for your discharge?

During your Police service, have you ever been, or were you ever, the subject of a complaint or suggestion of alleged misconduct? *

YesNo

What were the particulars of the allegation? What investigation took place? What was the outcome of the investigation?

12. Online Presence and Media

Social Media and Online Accounts

Online Account Details

Please disclose all current active accounts as well as all previous/inactive accounts, including under any different surnames, any informal names by which you are known, and any online pseudonyms that accounts may have been created in and closed or forgotten under.

Please provide all relevant usernames and URLs/website links to public/private profiles of the above accounts. If an account is no longer in use or deleted, please still provide as much information as you can for it.

LinkedIn

Prior to submitting your application, all applicants are to ensure that their LinkedIn is up-to-date (including updating descriptions for any former roles to past tense), and that any items that appear on both their CV and LinkedIn appear in a consistent manner.

I have reviewed my LinkedIn to ensure my profile is up-to-date and consistent to the extent any items are also listed in my CV. *

Do you or have you used any online dating accounts? *

YesNo

Personal Online Assets and Opinions

Have you ever owned a domain name, DNS certificate or operated your own website? *

YesNo

Please provide details, including the length of operation

Have you ever contributed to any blogging platforms attached to you or your spouse/partner such as WordPress, Medium or others? *

YesNo

Please list all online writings connected to you below, including URLs/website links to view the blogs

Are you a regular reviewer or have you provided a review under an account name to websites such as Amazon.com, TripAdvisor, Google reviews, Booking.com, Airbnb or others? *

YesNo

Please provide details of the reviews, including URLs/website links to view them

Have you ever participated in online gaming on your PC or any other gaming console such as Xbox, PlayStation or Switch? *

YesNo

Please provide details, including listing all usernames of any multiplayer online (role-playing) games or MMO usernames

Media History and Public Profile

Have you ever contributed to any online or print edition journals or magazines such as Quadrant, Spectator Australia, or others? *

YesNo

Please provide details, including the URL/website link to/image of the publication(s)

Have you ever had a Letter to the Editor printed or published online? *

YesNo

Please provide details, including the URL/website link to/image of the publication(s)

Have you ever contributed to a published academic paper, journal or research project? *

YesNo

Please provide details, including the URL/website link to the paper(s) and any other papers that referenced your original work

Have you ever taken part in a radio segment (including foreign-language programs)? *

YesNo

If available, please provide the recording(s) or the URL/website link where the segment(s) appear online

Have you ever appeared on television, including news programs, current affairs, and/or reality TV? *

YesNo

Please provide details, including the nature of the appearance(s) and the URL/website link to where the segment(s) can be viewed online

Have you ever appeared on/participated in any online-only programming or other content (including streaming/podcasts)? *

YesNo

Please provide details, including the nature of the appearance(s) and the URL/website link to where the segment(s) can be viewed/listened to online

Have you ever appeared before, or made a submission to, any Parliamentary committee or other inquiry (including whether as part of any group/company/organisation or whether at the Federal, State/Territory or local council level)? *

YesNo

Please provide details, including the nature of the submission(s) and inquiry/inquiries, and URL/website link to where any document(s)/report(s) can be viewed online

Have you, your family, your business/company or other organisation for which you were a director/officeholder (if applicable) ever been the subject of, or involved in, a public media controversy or adverse media coverage of any kind? *

YesNo

Please provide details, including the URL/website link to where this coverage can be viewed online

Online Security and Conduct

Have you, your family or your business/company (if applicable) ever been victims of online hacking and/or phishing attacks, or fallen victim to an online scam where you disclosed personal or private information? *

YesNo

Please provide details

Have you ever used social media to express or support opinions that, in a reasonable person's mind, could bring a person or an organisation with which the person is associated into disrepute? *

YesNo

This includes, but is not limited to, racist, sexist, demeaning or otherwise inappropriate material, including material that has since been removed, either by yourself, the author or the social media network/platform administrator.

Please provide details, including the material that was posted, the date on which it was posted, where it was posted, and any URL(s)/website link(s)

Have you ever transmitted an explicit image using electronic means, including email, social media or messaging services? *

YesNo

Please provide details, including to whom the image(s) was/were sent

Have you ever transmitted explicit text using electronic means, including email, social media or messaging services? *

YesNo

Please provide details, including to whom the message(s) was/were sent

Have you ever transmitted an explicit recording (audio or video) using electronic means, including email, social media or messaging services? *

YesNo

Please provide details, including to whom the recording(s) was/were sent

13. Personal Conduct

Personal Conduct Documents

All applicants must provide their National Police Certiﬁcate , detailing their Australia-wide disclosable criminal history.

Please upload your National Police Certificate *

Browse

Have you ever been charged with an offence which does not appear on your National Police Certificate? *

YesNo

Please provide details

Is there any reason you would not qualify for a Working With Children Check? *

YesNo

Please provide further details *

Have you ever been accused of an offence, including a traffic offence, in another State/Territory/Country? *

YesNo

Please provide details, including the date of the offence(s), and any enforcement action(s) taken by the interstate/overseas jurisdiction(s)

Have you ever been the subject of a complaint as to your personal conduct (including verbal abuse, intimidation, or violence) that is not already disclosed elsewhere in this application? *

YesNo

Please provide details, including whether the matter was investigated and by whom, and the outcome of the investigation

Have you ever been the subject of a complaint or suggestion alleging dishonesty, including forgery, fraud, or plagiarism? *

YesNo

Please provide details, including whether the matter was investigated and by whom, and the outcome of any investigation

Have you ever been the subject of a complaint or suggestion alleging improper access to information or a breach of any confidentiality/security obligations? *

YesNo

Please provide details, including whether the matter was investigated and by whom, and the outcome of any investigation

Have you ever been the subject of a complaint to Police or any other statutory or investigatory body? *

YesNo

Please provide details, including the particulars of the complaint/allegation, whether the matter was investigated and by whom, and the outcome of any investigation

Do you own any firearms? *

YesNo

Do you hold a current WA Firearms Licence and are all your firearms registered with the WA Firearms Registry? *

YesNo

Please provide further details.

14. Health

Do you have a medical condition that could affect your ability to serve as a candidate and Member of Parliament? *

YesNo

Please provide details

Have you ever been refused prescription medicines, or sought and/or obtained prescription medicines from someone other than your regular prescribing doctor? *

YesNo

(Except from a hospital or recognised after-hours medical service, or when travelling away from home.)

Please provide details

Have you ever used illicit substances? *

YesNo

Please provide details

15. Litigation

Have you ever had a court or tribunal judgement or warrant issued against you? *

YesNo

To the extent permitted by law, please provide details, including the court jurisdiction, the parties involved, and the date of the judgement or warrant

Have you ever been a witness in court or tribunal proceedings? *

YesNo

To the extent permitted by law, please provide details, including the court jurisdiction, the parties in the matter, the key dates in the matter, and why you were called to be a witness

Have you ever been subject to a compulsory examination by any statutory body? *

YesNo

To the extent permitted by law, please provide details, including the outcome of any related investigation

Is there any litigation or criminal proceeding, of any kind, pending against you or against a company in which you are or were a director or other officer or shareholder? *

YesNo

To the extent permitted by law, please provide details, including the court jurisdiction, the parties involved, that charge or cause of action, and the progress of the matter

Do you know of any circumstances which may, in the foreseeable future, give rise to litigation or criminal proceedings, of any kind, against you or against a company in which you are or were a director or other officer or shareholder? *

YesNo

To the extent permitted by law, please provide details, including the anticipated charge or cause of action against you, and the anticipated plaintiff

To the extent permitted by law, please upload a copy of any relevant court documents

Browse

16. Party Involvement

History of Political Involvement

When did you join the Nationals WA?

Why did you join the Nationals WA?

Have you ever been a member of a political party, other than the Nationals WA? *

Yes No

Please provide details, including the political party, the dates of membership, and the reasons you joined and left that party

Have you previously sought elected office (including in local government and any previous applications for endorsement by the Nationals WA or the National Party of Australia)? *

YesNo

Please provide details, including the electorate/division/ward in which you stood, the party you stood for (unless you stood as an independent), and the date of the election

Have you, or a company of which you were a director/other officer/shareholder at the time, ever donated financially or in kind to a political party, other than the Nationals WA or the National Party of Australia? *

YesNo

Please provide details, including the political party, the approximate date(s) of the donation(s), and the reason the donation(s) was/were made

Have you ever worked, voluntarily or otherwise, for a candidate or political party opposed to an endorsed Nationals WA candidate, or opposed to an endorsed candidate of the National Party of Australia? *

YesNo

Please provide details, including the candidate or political party for whom you worked, and in what capacity you worked

The Nationals WA Positions and Experience

Set out in full the details of the Nationals WA activities undertaken by you at each level and the position held in each Party Unit.

Please specify the name of the Party Unit and the year(s) that the position(s) was/were held.

If any Party Unit if not applicable to you (e.g. Young Nationals), please leave it blank.

Branch

Assembly Electorate Council

State Council

State Conference

State Executive

The WA Young Nationals

Policy Committee

List the campaigns you have been involved in, and the role you played in those campaigns

Outline any of your major influences on the development, direction, and achievements of the Nationals WA

Outline any significant contributions you have made to the Nationals WA in terms of leadership, innovation, policy direction, political thought, or administration

Reasons for Seeking Endorsement

Why did you decide to apply for endorsement to be the Nationals WA candidate for your nominated electorate?

What skills and experience (including any campaign skills, local networks, fundraising experience) do you feel make you well-suited to being the Nationals WA candidate for your nominated electorate?

17. General Disclosure

If endorsed as a Nationals WA candidate, you can expect considerable scrutiny of your personal and private affairs, as well as your public and business dealings. Matters that you consider private may not be treated accordingly by the media and your political opponents.

Disclosing any potential publicity risks now allows for those risks to be assessed and managed. It is also fundamental to satisfying the duty of full and frank disclosure that is required of applicants.

Failure to disclose any and all risks in full may be a cause for your exclusion as a candidate for preselection, or disendorsement if you are ultimately selected as the Nationals WA candidate.

Is there anything in your past or present about which, if it were to become publicly known, might distract from the campaign, or cause embarrassment to the Party, or you as a candidate? *

YesNo

Please provide details

Is there anything else you wish to disclose, or any other comments you wish to provide?

Declaration

I Declare

1. All information provided in my Application for Endorsement are true, correct, current, and complete in all respects.

2. Moreover, in consideration for being considered for selection as a candidate in accordance with the Constitution and Rules of the The Nationals WA for the forthcoming State election (Election), I agree to the following:

a) I will immediately provide any further information required by the State Director and undertake to consult with the State Director or to any anyone authorised by the State Director, of any change or the intention to make change to my personal circumstances (including a change of residential address or name) or commitments made in connection with the selection, or campaign;

b) I acknowledge that I may, but am not required to:

i. confirm that I have submitted an Application for Endorsement; and

ii. discuss my Application for Endorsement

with members of The Nationals WA, whether or not they are or may be preselectors, provided that:

iii. I disclose that I am participating in the Applicant Review process; and

iv. I do not disclose the result of my Applicant Review process to any person at any time except with the prior consent of the State Director; and

v. I do not obtain, seek, or receive any improper access to The Nationals WA’s confidential membership or other information; and

vi. I do not comment on or discuss any other actual or potential applicant(s);

c) I will not:

i. actively campaign for selection as a candidate; or

ii. obtain, seek or receive the public endorsement of other people, whether or not they are members of the Nationals WA

between the time that nominations opened and the time that the Nationals WA State Secretariat publicly conﬁrms the names of the applicants to be considered for endorsement;

d) I will not make any statement or comment to a journalist or media organisation in relation to my Application for Endorsement, any other actual or potential applicant(s) or the Applicant Review process.

e) In relation to publicly confirming that I have submitted an Application for Endorsement:

i. if I am currently an elected representative seeking endorsement for the position that I hold, I acknowledge that I may confirm that I have submitted an Application for Endorsement to a journalist or media organisation without requiring the further approval of the President or State Director provided no further comment is made, or

ii. if I am not currently an elected representative, or I am currently an elected representative seeking endorsement for a different position from the one that I hold, I acknowledge that I may confirm that I have submitted an Application for Endorsement to a journalist or media organisation only with the prior approval of the President or the State Director, and that no further comment may be made;

g) If I am not selected as a candidate:

i. I will accept and abide by the decision as having been made in the best interests of The Nationals WA;

ii. I will not contest the Election or in any way support any candidate or party in opposition to The Nationals WA endorsed candidate;

iii. I will not engage in any conduct designed to or having the effect of disparaging The Nationals endorsed candidate or The Nationals WA or engage in any other conduct which may adversely impact upon the electoral prospects of The Nationals WA or its endorsed candidate;

h) If I am selected as a candidate:

i. I acknowledge I am bound by the Constitution and Rules of the Nationals WA and I will support and advocate its objectives, policies, and election platform, and will not advocate policies which are inconsistent with them;

ii. I will comply with any lawful directive of the State Director and the State Secretariat of the Nationals WA and any decision of the State Executive, State Council,Central Campaign Committee, and my local Campaign Committee;

iii. I will do all things and sign all documents as requested to ensure compliance with relevant electoral laws;

iv. I acknowledge that if I am successful in being endorsed as a candidate, a Candidate Agreement will be required to be signed that outlines speciﬁc campaign and other requirements, and I undertake to acquaint myself with its terms and raise any issues in relation to it at the earliest opportunity;

v. I will conduct my campaign within such budgets and ﬁnancial limits as are approved by my local Campaign Committee and the Central Campaign Committee. I agree that should I not do so I will be personally liable for any additional expense incurred and should The Nationals WA pay any such additional expense it will immediately become a debt due and owing by me to The Nationals WA;

vi. I will abide by the financial policies of The Nationals WA;

vii. I will not accept any donation or other beneﬁt whether in money or in kind, which imposes upon me a guarantee, pledge or undertaking, or which places or might place me in a position in which there could be a conflict between my personal interest and my duties to The Nationals WA and/or as a Member of Parliament, should I be elected;

viii. I will ensure that my campaign and any fundraising is conducted in accordance with the law including any fundraising disclosure requirements;

ix. I acknowledge that during my term as a Member of Parliament the Party may impose a charge, fee, or levy on members of the Party who are members of the Western Australian Parliament by by-law, resolution of the State Executive, or otherwise and agree that, if it does so, I will pay the charge, fee, or levy in accordance with the terms of payment stipulated by the Party, including any additional amounts imposed in respect of late payment;

x. If asked to do so by the State Director, I will make such arrangements and sign such documents as may be required for the charge, fee, or levy to be paid by direct debit, charge against my credit card, or otherwise as the State Director may stipulate;

xi. If I do not comply with the above, I acknowledge that I may be disendorsed as a candidate and could face disciplinary action under the Constitution and Rules of The Nationals WA.

Signature of Applicant *

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Application Fee (non-refundable)

A non-refundable Application Fee of $2,750.00 inc GST is required for this application. You can pay either by card below or transfer the $2750.00 to our bank account using the details below:

BSB: 633-000

Acct: 139872022

Reference: 180-1 [LAST NAME]

If you choose to pay by card, an extra card fee of $49.29 will be included.

If the payment is not received within 3 business days of the application's submition, the Application for Endorsement will not be considered.

Payment Method *

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