National Police Service Medal

Tasmania Police

NB: The information requested in this Application is to assess the eligibility for awarding the National Police Service Medal (NPSM) with regard to the Amendments published in the Gazette C2014G00624 on 15 April 2014.

An e-mail address is mandatory. Members of the Retired Police Association who do not have an e-mail address may provide the RPA's address where required. It is "rpatas1@gmail.com".

1. Details of nominee (the proposed recipient)

Is this application being made on behalf of the Awardee (ie Incapacitated/Posthumous)?



Please enter at least one phone number:

Residential Address

Postal Address

Has the nominee ever been known by or used any other name? *
Died during service as a police officer or could not continue service as a result of injury or disability sustained in or as a result of police service, prior to qualifying period of 15 years

Has the nominee previously received the below medals?

National Medal
Police Long Service & Good Conduct Medal

2. Details of Service of nominee

Please enter a record for each separate period of sworn service (not trainee/cadet service), in any order. Use the + and - buttons to add and remove service periods.

3. Details of person making the application

4. Declaration of Executor, Administrator, Guardian or Next of Kin

I have enclosed proof that I am the Executor of the will, Administrator in case of intestacy, Power of Attorney, or a person who can prove legal status as a beneficiary to this claim.

I do solemnly and sincerely declare that I wish to apply for the unclaimed National Police Service Medal in respect of the infirmed/deceased ex-member whose details are provided in this application.

I declare that I am the entitled to receive the NPSM. I hereby indemnify policing organisation/s against any claim arising from the incorrect award of the medal.

5. Declaration by applicant

I declare that the information I have given in this document is true and correct to the best of my knowledge. I understand that it is an offence to knowingly give false or misleading information contrary to section 137.1 of the Criminal Code 1995 (Cth), an offence punishable by a term of imprisonment of 12 months;

I understand that information provided in this application will be disclosed to policing organisation/s and other government agencies to validate policing service and conducting a National Police Check or equivalent on the proposed awardee;

Information provided will be disclosed to Australian Honours & Awards Secretariat at Government House Canberra, as part of approval process.

I declare I have been advised how my personal information will be used to record me for the NPSM and I have read, understand and agree to Australian Privacy Principles 12 March 2014. (included in application pack or www.oaic.gov.au, privacy fact sheet17)

I declare that my service as a sworn officer of police was ethical and diligent (not required if Executor, Administrator, Guardian or Next of Kin)
Cancel
Tasmanian Government

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