Election of Board Directors 2026 Nomination Form

PART 1: Candidate details

First name *

Middle name(s)

Last name *

Are you known by any other name? *

YesNo

Other name(s) *

Please indicate the title you use (eg Mr, Ms Dr, Mx): *

Date of birth *

Place of birth *

Residential address *

Street address *Street address line 2

City/Town *

State *

Postcode *

Postal address *

Street address *Street address line 2

City/Town *

State *

Postcode *

Daytime phone number *

Mobile phone number *

Email address *

Do you identify as Aboriginal or Torres Strait Islander?

YesNo

Do you have a Director ID number? *

YesNo

Director ID number *

All directors of Australian companies need a director ID. If you plan to become a director, you must apply for a director ID before you’re appointed. Further information regarding Director IDs is available here.

PART 2: Professional details

Current employer/professional role/background/experience *

Qualifications *

Current and past memberships of relevant boards, committees or organisations *

Response to desired skills and attribute

Please indicate below whether you hold experience in any of the following fields. You may select more than one if this applies to you.

Finance – executive leadership including CFO (CA, CPA) Data and digital, including health intelligence, digital health, data analytics, and AI literacy Corporate governance, including serving as a Company DirectorGeneral practitioner – primary care rural generalist

PART 3: Candidate statement

Please provide your statement *

Candidate photo *

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A profile photo will be included with your candidate statement when distributed to firsthealth Limited members in the ballot papers. Photos must be a minimum of 600x600 pixels and in jpeg or png format.

PART 4: Candidate declaration

I have read and understood all parts of the Information for Candidates webpage and this Nomination Form.

I agree to abide by and support the Constitution of the company.

I declare that the information provided in my nomination is correct, and I understand that any claims I have made are subject to verification by the company.

I submit this nomination as a candidate for election as Board director for firsthealth Limited.

I accept that certain aspects of my application may be shared with firsthealth Limited members for their consideration in voting in the election of directors, and with current firsthealth Limited directors and the company’s auditors in the course of the distribution of the Annual General Meeting materials.

*

Full legal name *

Signature *

Clear

Date *

PART 5: Nomination method

Prospective Director candidates must be nominated by a member of firsthealth Limited, through the nominated representative, or a retiring Director of firsthealth Limited.

After you submit this form, an email will be sent to your nominated representative or retiring Director asking them to review the nomination and provide their declaration and digital signature.

Please check that the nominator’s name and email address are correct and let them know to expect an email from no-reply@snapforms.com.au.

This form is not complete until your nominator has submitted their declaration and signature.

Nominating Member details

I am seeking nomination by *

A member of firsthealth Limited, through the nominated representative A retiring Director of firsthealth Limited

Member Organisation name *

Nominated Representative name *

Nominated Representative email *

Retiring Board director name *

Retiring Board director email *

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