Canberra - Information Session 10 May 2017

Please provide us with the following details for travel, accommodation arrangements and catering requirements.

If you are not attending, please complete the first four questions then scroll to the foot of the form and click Submit

Please confirm*

Yes, I will be attendingNo, I will not be attending

Title

1. Name *

First NameLast name

Preferred Name

2. Your email*

3. Age range*

18-3031-5556 +

4. Gender*

FemaleMaleX (Indeterminate/Intersex/Unspecified).

5. Mobile number*

Alternative contact number

Postal address*

Address

Address Line 2

CityState / Territory

Post Code

Emergency contact name

Emergency contact phone number

Required travel option*

Live locallyDriving

Please advise if you are driving your private vehicle or a work/ organisation vehicle*

Private vehicleWork/organisation vehicle

Travelling from*

Returning to*

MILEAGE ALLOWANCE

Mileage allowance will be capped to the equivalent of the relevant public transport fare or airfare from your home location to the meeting location (if available) on the day of travel.

MILEAGE ALLOWANCE

Mileage allowance will be capped to the equivalent of the relevant public transport fare or airfare from your home location to the meeting location (if available) on the day of travel. It will be paid to your employer/organisation (subject to approval).

STATEMENT OF INDEMNITY

I shall be driving my own vehicle to and from the First Nations Regional Dialogue. I certify that I have a current drivers licence and that the vehicle is appropriately registered and insured.

I indemnify the Commonwealth against claims for damages and/or injury during the period for which I am claiming mileage.

I hereby acknowledge that I fully understand this Statement of Indemnity*

I agree

ACCOMMODATION, DIETARY REQUIREMENTS & SUPPORT

Will you need accommodation?*

YesNo

Do you require taxi vouchers?*

YesNo

Number of taxi vouchers required *

Purpose of use*

Do you need accessibility or other form of support?*

YesNo

What type of support is needed?

Do you have special dietary needs?*

YesNo

What dietary requirements do you have?*

Other special dietary needs - please specify

TERMS AND CONDITIONS

Reasonable costs for travel, accommodation and meals will be provided by the Referendum Council, through AIATSIS.

Some meals will be provided at the dialogue. Others will be arranged with your accommodation, including in any in-transit accommodation.

Where meals are required during travel to and from the dialogue, for those travelling on a bus arranged by us, we may arrange for meals to be provided at one of the bus rest stops or for a payment to be made after the dialogue. For those travelling by car, a payment will be made after the dialogue.

If you are eligible for mileage allowance, 50% will be paid in advance of the dialogue, and the remaining 50% will be paid after the dialogue.

PLEASE NOTE:

It is expected that you will attend all three days of the dialogue. Unless otherwise agreed, if travel arrangements have been made for you to attend the meeting and you do not attend on all three days, you will not be paid mileage and/or in-transit meal/s for your return journey.

If you do not attend the meeting at all, AIATSIS may seek to recover all costs. This includes mileage allowance, travel and accommodation costs, and any meals booked and paid for you in advance. This will be decided on a case-by-case basis.

I HAVE READ AND AGREE TO THE ABOVE TERMS AND CONDITIONS

BANK DETAILS

You may be eligible for a meal payment, depending on travel schedule. To assist us in providing you a payment please provide your bank account details below.

Account name*

BSB*

Account number*

MEDIA CONSENT

I grant AIATSIS and the Referendum Council a non-exclusive royalty free perpetual license to use the photographs/videos taken at the Regional Dialogue; to make this material available for public access and use for research purposes; to make copies of the material in other formats including digital format; to use the material in AIATSIS and Referendum Council publications including digital products; to reproduce the material and to publish selected parts of the material on the internet (including the websites of AIATSIS and the Referendum Council); and to deposit in the AIATSIS and Referendum Council archives.*

YesNo

If you have any problems completing the form or would like to speak to a staff member, please email cric@aiatsis.gov.au or call the CRIC team at AIATSIS on 1800 953 353 between 9am-5pm Monday to Friday.

Canberra Information Session 10th May 2017