Australian Fire Service Medal Nomination Form · Web viewAuthor bbudge Created Date 12/11/2016...
Transcript of Australian Fire Service Medal Nomination Form · Web viewAuthor bbudge Created Date 12/11/2016...
ective date: 31/08/16
Australian Fire Service Medal (AFSM) Nomination
Part One – Nominee details
Surname: First names:
Payroll/Volunteer ID No.: Rank/position:
Region: Please select: Date of birth: Work location:
Home address: Postcode:
Phone: Email:
Previous awards received (include award name and year awarded):1. 2. 3.
Part Two – Nominating officer details
Name: Position:
Location: Region: Please select:
Email:
Part Three – Nomination statement
Detail how the nominee has provided distinguished service as per award criteria:
Part Four – Endorsement by nominating officer
I endorse this nomination and have attached three reference statements to support this nomination.
Signed: Date:
Queensland Fire and Emergency Services is collecting personal information for the purpose of processing nominations subject to the requirements of the Information Privacy Act 2009 (the IP Act) which are defined in the 11 Information Privacy Principles (IPPs). For information on the 11 IPPs, refer to Schedule 3 of the IP Act.
PUBLIC Page 1 of 1This document is maintained in electronic form. The approved version of this document is located on the QFES Website
and is uncontrolled when printed. It is the responsibility of the user to verify this copy is the latest version.